I'm not much one for games, but I do love cities, and from what I'm hearing, it might be worth my while on this occasion to look further afield than Candy Crush and Freecell and check out Cities: Skylines.

You'll do some very big things, like planning entire regions and suburbs, but you'll also be doing some very small things. There's a surprising amount of micromanagement in the game once you progress and pick at it, and while some of it sucks (more on that below), other parts are great. Public transport is one such highlight: instead of just dropping depots, stations and stops on the map, Skylines lets you actually plan out specific routes for each mode of transport. Being able to manually assign bus routes and subway lines feels great, like you've got more precise control over the movement of the people in the city.

That sounds really cool! I haven't been this excited about computer-simulated urban design since the late-'80s days of Sim City's original two-dimensional incarnation.

And that incarnation, argues Ian Bogost, was distinctly American in its outlook:

Maxis’s games have hardly escaped criticism. Game design is a process of abstraction, and you can’t simplify a complex system like the operation of cities without consequence. SimCity was profoundly but weirdly American in its assumptions. Taxation caps out at 20 percent, a level far below what would be needed to operate a social welfare state city like, say, Copenhagen. And at higher tax levels, Sims go on strike or move out of town in disgust. But even in such a seemingly American context, race plays no role in the operation of one’s simulated cities, and the classic features of American sprawl—highways, exurbs—weren’t possible in the earliest versions of the game, even as rail transit has always remained the best way to reduce traffic and increase density in a SimCity metropolis. The game’s most recent version did even stranger things, casting residents as a kind of bizarre blend of middle class laborer and migrant worker, and making homelessness rampant, causing players to reveal curious and sometimes uncomfortable truths about themselves and the world in their quest to (virtually) eradicate it.

So perhaps a bit like America in the first half of the 20th century, before the Eisenhower-led Interstate System (and without any of that embarrassing redlining and segregation)?

It turns out that the latest edition of Sim City might also unintentionally reflect current American ideas about contemporary problems facing cities. Among other difficulties, players of the game have to address homelessness — and like real city-leaders, they find the problem a vexing one. Matteo Bittanti collected online discussions about how to deal with (virtual) homelessness:

For Bittanti, it's impossible not to see the connections between the homeless problem in the Bay Area and the way it's portrayed in SimCity.

"That is, can we fix homelessness in SimCity, or because we haven't fixed homelessness as a problem in real life, therefore we are bound to lose?" Bittanti asked. "Is SimCity a reflection of what's happening in reality, and therefore is very realistic, or is it a programming issue?"

And maybe this has something to do with the IRL America, too:

Bittanti says that it's impossible to distinguish between videogames and America in the same way that Jean Baudrillard thought it was impossible to distinguish between Disneyland and America. The book, he told me, is about simulation and its discontents, the unexpected convergence and collapse between reality and simulation.

"To me video games are the so-called 'real America,'" he said. "The real America operates according to a video game logic, and that game logic is neo-liberalism, and that absolutely manifests in San Francisco, that to me is the epicenter of inequality. In San Francisco you either have a Tesla and you drink a seven dollar cappuccino or you're homeless in the streets."

From the Bogost piece, it seems that wonks during the early '90s could not only live out their urban design fantasies, but also pursue their interests in health care reform:

In at least one case, the 1994 title SimHealth, Maxis attempted a title of this sort that would soon after be called “serious games.” A complex management simulation of the U.S. healthcare system, SimHealth was released amidst debate around then-President Bill Clinton’s proposed Health Security Act, an attempt to reform U.S. healthcare in ways that wouldn’t be taken up again until Obama’s Affordable Health Care act.

The Supreme Court wll hear arguments for a new challenge to Obamacare this week, though unlike the previous challenge to the law, the case surrounds not the constitutionality of the act but matters of drafting. As Jeffrey Toobin says, it's hard not to see the argument as frivolous:

The A.C.A. created federal tax subsidies for those earning less than a certain income to help pay for their premiums and other expenses, and, in describing who is eligible, Section 36B refers to exchanges “established by the State.” However, thirty-four states, most of them under Republican control, refused to create exchanges; for residents of such states, the law had established a federal exchange. But, according to the conjurings of the C.E.I. attorneys, the subsidies should be granted only to people who bought policies on the state exchanges, because of those four words in Section 36B. The lawyers recruited plaintiffs and filed a lawsuit; their goal is to revoke the subsidies provided to the roughly seven and a half million people who were left no choice by the states where they live but to buy on the federal exchange.

The claim borders on the frivolous. The plaintiffs can’t assert that the A.C.A. violates the Constitution, because the Justices narrowly upheld the validity of the law in 2012. Rather, the suit claims that the Obama Administration is violating the terms of its own law. But the A.C.A. never even suggests that customers on the federal exchange are ineligible for subsidies. In fact, there’s a provision that says that, if a state refuses to open an exchange, the federal government will “establish and operate such Exchange within the State.” ... This lawsuit is not an attempt to enforce the terms of the law; it’s an attempt to use what is at most a semantic infelicity to kill the law altogether.

What I do not understand about this is not whether the Court is cynical enough to use this case to undermine a law to which its majority is ideologically opposed — from Bush v Gore to Burwell v Hobby Lobby, many of the current sitting justices have demonstrated their willingness to consider creative interpretations of the law if they advance political goals they support. But rather, why now and why this case?

Obviously, if the court rules against the government, this will have far-reaching implications for the insurance markets in the states that have those exchanges. Many people who are currently buying policies will probably decide to drop them if they have to pay full price — and the people who decide to keep buying that insurance are more likely to be those whose insurance costs exceed the monthly premiums, which is to say older and sicker people.

Indeed, the disruption to the insurance market might result in such chaos that some observers have suggested Republicans would prefer the Court to uphold the law. If the Court had struck Obamacare down in 2012, before it had been implemented, the Republican victory would have been clean and complete: a law they didn't like would never have been put into practice. But Obamacare is currently providing millions of Americans with affordable insurance, and if those voters lose access to the subsidies providing for that, Republican lawmakers and candidates will come under immense pressure to fix the problem:

The outcry for a fix will be broad, sustained, and lockstep, but it will meet wildly different audiences. Everyone in the GOP primary field will face extensive pressure to treat an adverse decision as an opportunity to get rid of the law altogether, but some of them will be governors or former governors who won’t be as amenable to using constituent suffering to leverage an unrealistic political goal. Republican Senate candidates from the above-mentioned Wisconsin, Ohio, and Florida, but also from Pennsylvania, New Hampshire, Illinois and elsewhere, will quickly see their political fortunes become entwined with the cause of fixing Obamacare.

Chief Justice John Roberts probably dislikes Obamacare as policy. But even if he were willing to use his power to undermine the law, why would he do so now, when the outcome will be indeterminate and a potential source of difficulty for conservatives, when he chose not to in 2012? John Roberts had the perfect opportunity to kill Obamacare, and he did not take it. What reason would he have to take this imperfect opportunity?

Health and human services secretary Kathleen Sebelius has announced she is resigning:

Kathleen Sebelius, the health and human services secretary, is resigning, ending a stormy five-year tenure marred by the disastrous rollout of President Obama’s signature legislative achievement, the Affordable Care Act.

Mr. Obama accepted Ms. Sebelius’s resignation this week, and on Friday morning, he will nominate Sylvia Mathews Burwell, the director of the Office of Management and Budget, to replace her, officials said.

Few people will be looking to defend Sibelius; the website launch was a mess and, considering she was in charge of implementing President Obama's signature policy, it seems entirely appropriate the Secretary should take the fall for Obamacare's shaky start. (Even though she was able to announce before stepping down that the website had succeeded in enrolling 7.5 million Americans in new health insurance policies, beating the Administration's original target of 7 million enrollees.)

But as Americans bid Sibelius a not particularly fond farewell, let's give the program and its infamous web portal credit where it's due: Healthcare.gov was not subject to the Heartbleed bug, which potentially exposed websites using supposedly secure incryption to unauthorised access. This is from Mashable's round-up of Heartbleed-affected sites:

This puts the Obamacare site ahead of Yahoo, Gmail, and some Amazon services! If only it had always performed so well.

Exchanges are the virtual marketplaces where people without employer insurance will buy coverage. A big question is what options will be available, and at what prices. Insurers submitted their bids a few weeks ago and the states have started making those bids public. Those of us who follow health policy were waiting to see what happened in California—partly because it’s so large, and partly because it has not traditionally regulated insurers very closely.

That last part is really important. Under Obamacare, premiums for some people are bound to go up, because the law requires insurers to cover people they presently turn away for pre-existing conditions—and to provide the kind of comprehensive benefits insurers frequently don’t offer when selling to people on an individual basis. But how high will those premiums go? The answer does not affect the majority of people directly. The law’s subsidies limit what most will pay for coverage, no matter how high the premiums go. But it affects the behavior of people with household incomes of more than four times the poverty line. And if the premiums come in much higher than expected, the subsidies would get a lot bigger, putting a greater strain on the federal treasury.

The Congressional Budget Office predicted back in November 2009 that a medium-cost plan on the health exchange – known as a “silver plan” – would have an annual premium of $5,200. A separate report from actuarial firm Milliman projected that, in California, the average silver plan would have a $450 monthly premium.

Now we have California’s rates, and they appear to be significantly less expensive than what forecasters expected.

On average, the most affordable “silver plan” – which covers 70 percent of the average subscriber’s medical costs – comes with a $276 monthly premium. For the 2.6 million Californians who will receive federal subsidies, the price is a good deal less expensive[.]

Imagine an alternative universe where after the stimulus President Obama made carbon pricing instead of health care reform his top legislative priority. Let's say the bill passed but provoked a backlash similar to that of Obamacare — causing Dems to lose the same number of seats as they did in 2010. And imagine that currently the law holds approximately the same levels of public support and chance of repeal as Obamacare does. Is this an alternative universe you'd want to live in?

The Sandy Hook school shooting in Connecticut is a terrible tragedy. America must once again reflect on its gun culture. Just like the Columbine, Red Lake, and Virginia Tech incidents, regulation advocates have come out in force. Dan Gross from the Brady Campaign to Prevent Violence asserts that “we’re really poised to harness that outrage and create a focused and sustained outcry for change.”

Such rhetoric was sounded when Gabrielle Giffords was shot, but little change occurred in the aftermath. With the debt deficit talks now being discussed in Congress, federal lawmakers are in no position to meaningfully address the gun debate. By the time President Obama addresses this issue next year, the Sandy Hook massacre may sadly become lost in a myriad of other school shootings. This is due to the NRA’s influence in Washington and that the mythology of the second amendment is so pervasive. With 300 million guns in the US, it’s incredibly hard to provide effective regulation.

On the other side of the debate, pro-gun lobbyists and Republicans maintain that “guns don’t kill people; people kill people”. There’s some truth in this statement. Lawmakers must realise that gun control is not only about regulating guns but also addressing mental health issues among young vulnerable men. Men such as Eric Harris, Dylan Klebold, and Adam Lanza were no doubt distressed and alone. Their internal pain caused them to unleash it upon innocent children and students. Their actions are inexcusable, but if help was provided to them such tragedies may not have occurred. Matt Driscoll from the Seattle Weekly summed this up well when he wrote: “The reality is that guns are easier to get than mental health treatment”. In other words, firing a gun on innocents is more accommodating that than talking to somebody about your problems. It’s no wonder that most school shootings involve the gunman turning on himself.

If local community leaders such as teachers, police, pastors, friends, and family can identify men who might do something drastic, the chance of another school shooting may be avoided. This would involve federal and state government investment through community based organisations. The NRA can also get involved by championing the fact that shooting innocents does not solve one’s problems. This would improve their image. Opponents to this policy will point out that such spending will still allow vulnerable men to fall through the cracks and school shootings to occur. That may be so, but it’s far better to take this bipartisan approach than to be squabbling over gun regulation for years.

Having mental health background checks and reinstating the assault weapons ban is a positive step in curbing violent rampages in schools. Unfortunately, shootings will continue to occur in the future. President Obama must realise that regulating guns is only a small part of the picture. If Obama addresses the mental health side, he has a much stronger chance of leaving a legacy.

As commentators on both the left and the right have noted, it's the working poor, not the rich, who are paying the highest effective marginal tax rates. This isn't because they are paying a greater percentage of their income in taxes, but rather as their income rises they lose eligibility for certain means-tested welfare programs.

I've heard some grumbling from conservatives that the subsidies in Obamacare will only worsen a tax system that they believe already significantly disincentives work. People will now have to account for a whole new series of benefits that phase out as you move up the income scale.

I haven't looked deeply enough to answer this question definitively, but my guess is that the law will actually have the opposite effect. To some extent, high marginal rates on the poor are an inevitable and worthwhile trade-off if we want to guarantee a basic social safety net. But, a specific problem with the U.S. tax code and welfare benefits is the lack of harmony between state and federal policies. Supply-siders overstate the impact of tax rates on behavior, but you do end up with some harmful marginal rates that could be smoothed out if there was more central oversight. By creating a more uniform health care system Obamacare takes some steps in addressing this problem.

The biggest change is that Obamacare makes the phasing out of healthcare benefits much more gradual. Before, Medicaid covered some Americans living below the poverty line but there was basically no governmental assistance for anyone else below the age of 65.* As such, there was a huge incentive for some of the most vulnerable citizens to try and keep their Medicaid coverage.

Under the new law, everyone up to 133 per cent of the federal poverty line is eligible for Medicaid. And after that, individuals and households making up to 400 per cent of the poverty line receive subsidies to help them buy insurance in the new state exchanges. The benefits are provided on a sliding scale, with poorer Americans having to pay a lower percentage of their premiums.

So it's true that the reform will have an impact on the marginal tax rates of millions of Americans. But now, no one has to worry about losing their healthcare coverage if they get a better job, and the amount of governmental support for purchasing insurance is more continuous and subtle across different income levels.

Barack Obama ended his victory speech in Chicago last night with the words: “And together, with your help and God’s grace, we will continue our journey forward and remind the world why it is that we live in the greatest nation on earth". These words will ring hollow unless American politicians can work out how a Democratic President can negotiate lasting deals with a Republican-controlled House of Representatives.

In the short term, the opportunity for compromise is better on economic matters than it has been for years. At the end of this year, the George W Bush tax cuts will expire. Obama will not wish to see this happen, as they contain cuts to middle-income taxpayers that he has promised to keep.

However, Obama will want to see the top marginal tax rate for people earning over $390,000 to increase from 35% to the high 30s. Without a deal, the rate will default back to 39.6%, the same rate that was in place for the Clinton presidency which paid off the debts of the Reagan Administration and enjoyed impressive economic growth in the mid-to-late 1990s.

These taxation options should have been one of the key issues of the presidential campaign, setting up Obama’s more Keynesian approach against a pitch for Reaganomics. This seemed for most of the year the type of campaign promised by Romney. However, it never really happened because both campaigns focused on clichés and ground-game while the media frequently forgot to ask either Obama or Romney to explain their tax plans.

Romney also moderated his position over time on taxation (as he did towards the end of the campaign on a number of issues, making him once again appear to be the “multiple choice” candidate, a label that Edward Kennedy first used for Romney in 1994). Most shameful was Romney’s secret plan on tax reform where he pledged to not increase taxes for the wealthiest Americans. Instead, he would close loopholes and deductions to fund the revenue that would have come from ending the Bush era tax cuts.

This sounded too good to be true, and it was. The actual loopholes and deductions were never named and on that basis alone Romney deserved to be defeated for keeping a central policy secret from the voting public. He also deserved to lose because of the multiple positions he took on a variety of policy issues: of course the GOP primaries make it hard to not tack to the right and then have to tack back to the centre; however, Romney’s reversals went beyond canny political sailing and entered into a more cynical realm of “I hope the public ignores what I said earlier this year (or month) on this issue". Consistency in politics has to mean something, or we might as well choose politicians via a lottery.

The other big economic issue looming is the “fiscal cliff” that America is set to go over in early 2013, unless a deal can be reached between the president and the congress on spending cuts. If no deal is reached, automatic cuts that few politicians really want will come into action.

Washington’s politicians are involved in a game of policy chicken that could have devastating results — not only for America, but for the world. The Republican proposals outlined in the Paul Ryan budget plan are not going to be acceptable to the President, particularly cuts to programs affecting the poorest and most vulnerable Americans. Ryan’s idea of vouchers is also unlikely to have any Democratic party takers. Ryan’s best idea is means testing retirement and medical benefits; the Democrats seem wary of this idea, presumably because it could be the beginning of a move to fully privatise Social Security and medical coverage for Americans.

These proposals raise interesting philosophical questions about whether universal or progressive benefits for the elderly are desirable. On the basis of both cost and coverage, a more universal public health system coupled with means-tested retirement benefits is the road ahead that American politicians should consider. However, only incremental changes on these crucial issues are likely in Obama’s second term.

The only American politician I saw who put detailed and well thought out economic policies at the forefront of their campaign was Elizabeth Warren in her successful Senate campaign in Massachusetts. Warren, a Harvard Professor, is an expert on the financial problems experienced by Americans who have been bankrupted by their medical bills or mortgage payments. Debates in the US Congress could do with input from just such a policy expert as Warren. Her questioning of Treasury Secretary Tim Geithner in a Congressional inquiry over where the $170 billion the US government gave AIG went is a rare moment of pushback and inquiry into the world of high finance.

On the campaign trail, Warren — unlike Obama — talked frequently about inequality, often quoting studies. She argued convincingly that the Republican economic approach inspired by the Reagan Administration of trickle down tax policy, deregulation, deindustrialisation, and limited government had failed. Obama talked about economic fairness in a much less direct manner, leaving what he would do to address inequality very open to conjecture.

In terms of extending Obamacare to more seriously reduce America’s incredibly high health costs — the highest in the OECD by a considerable margin — Warren has crunched the numbers to find that the public system is much more cost efficient, contradicting Romney’s faith-based comment in the first presidential debate that the private system does better than the public in health care delivery.

With nearly 19% of American GDP being spent on healthcare, addressing the health care cost blowout is crucial to America maintaining its status as a global super power. That might sound dramatic but health expenditure is not a great way of stimulating growth in the economy — this money could be spent more wisely elsewhere. Furthermore, the government is paying far too much for services because of the role of insurance companies in inflating costs, massive inefficiencies in having so many separate providers, and over servicing from doctors who are often overpaid.

If the second Obama term is to deliver on economic matters, these big questions need to be addressed and outlined more directly, not only in the broad economic philosophy favoured by his administration, but also by concretely addressing more specific issues like how best to keep medical costs under control. My concern is that for all of Obama’s reputation as a visionary president, he has so far in fact been a status quo president who has often been too lost in the details of events to argue for bold new policies.

Obama’s résumé of accomplishments is broad and deep, running the gamut from economic to social to foreign policy. The general thrust of his reforms, especially in economic policy, has been a combination of politically radical and ideologically moderate. The combination has confused liberals into thinking of Obamaism as a series of sad half-measures, and conservatives to deem it socialism, but the truth is neither. Obama’s agenda has generally hewed to the consensus of mainstream economists and policy experts. What makes the agenda radical is that, historically, vast realms of policy had been shaped by special interests for their own benefit. Plans to rationalize those things, to write laws that make sense, molder on think-tank shelves for years, even generations. They are often boring. But then Obama, in a frenetic burst of activity, made many of them happen all at once.

This captures a curious quality of the Obama administration, one that has frustrated both his supporters and his opponents, but might, as Chait says, bolster the President's legacy in yeas to come. Throughout his first term, Obama has exhibited a practice of behaving moderately to achieve deeply partisan ends. His health care bill represented the culmination of more than a half century of liberal effort to expand the welfare state, but the law he enacted to achieve it was modelled on a proposal originally put forward by the Heritage Foundation, a conseravtive think tank, and didn't even include a public option. On gay rights, Obama frustrated his base with moves so slow that they approached stationary, but he's nonetheless ended his first term with Don't Ask Don't Tell dismantled and the Defense of Marriage Act winding its way through court challenges undefended by the Justice Department. The $800 billion stimulus package of 2009 was as large as could be extracted from Congress, but it had far more in the way of weakly stimulative tax cuts than a model Keynesian proposal.

Part of this mix of radicalism and moderation is the result of strategy — Obama campaigned on bridging the partisan divide in Washington, and, at least until the debt ceiling fight, he seemed to believe he could achieve that goal. As such, he was happy to offer proposals with Republican-friendly compromises built in. (Republicans balked; the President's spoonfuls of sugar couldn't persuade them to swallow policy ends they fundamentally loathed.) But it may also be that Obama has a natural tendency toward conciliation. The result is a strange and much-criticised creature: the moderate of liberal despair and the radical of conservative nightmare.

Last month I wrote that it was difficult to envision a scenario in which Romney won the presidency but Democrats maintained control the of the Senate. It seemed a safe assertion. The president was a decent favourite to win re-election and the Senate was on a knife's edge. If Romney managed to mount a comeback it was overwhelmingly likely that his coattails would give Republicans the slight nudge they needed to take over the Senate as well. And even if we ended up with a 50-50 split in the upper chamber Vice President Ryan would cast the tie-breaking vote when things were deadlocked.

However, much has changed over the last month.The presidential race has tightened considerably leaving President Obama in a much more vulnerable position. At the same time, the battle for the Senate has moved decisively in the opposite direction. What were supposed to be close races in Florida and Ohio are now looking looking quite safe for the Dems. And they're also exceeding expectations in Arizona, Massachusetts, Indiana, Wisconsin and North Dakota. As of today, Nate Silver gives the Democrats an 86.4% chance of holding the Senate while a Republican majority isn't even within Sam Wang's 95% confidence interval.

This is significant. It's no secret that Paul Ryan and the Republican-controlled House have spent the last several years formulating plans to drastically scale back the social safety net and gut non-defense discretionary spending. And Romney has said his first priority in office will be to repeal Obamacare.

A Romney administration with a Republican controlled Congress would have the tools to pursue this agenda. The legislative process known as reconciliation allows the Senate to pass certain budgetary measures with only 51 votes. As such,while parsing out the intricacies of parliamentary procedure is difficult, it's likely that you could dismantle large segments of Obamacre and cut off funding for other programs without a filibuster proof majority.

Without control of the Senate the task becomes substantially more difficult. President Romney could grant waivers for states to exempt thems from portions of the health care law but you're never going to get anywhere close to a full scale repeal without help from the legislature.

To be clear, I'm not downplaying the importance of the election. I've actually been meaning to write something on how much I think is at stake in 2012. And Republicans still have a great chance of retaking the Senate in 2014. But if Romney wins the presidency the Senate is a far from insignificant consolation prize. A crucial check on a Republican Party that's been uncompromising in pursuit of it's hard-line agenda.

Thanks goodness for co-bloggers. I haven’t yet had a chance to write on the Ryan VP pick but luckily Jonathan’s been doing a phenomenal job of picking up the slack. He’s already touched on a lot of the big issues so I have to find a different angle.

The pick will at least temporarily push the debate over Medicare to the forefront of the election. The Ryan plan would effectively end Medicare as we know it. The public health insurance program for seniors would be replaced with a voucher system in which in which citizens purchased their own private coverage. Notably, the subsidies would be indexed for inflation instead of rising health care costs. Medicare cuts are typically viewed as a third rail of American politics and not surprisingly the Ryan reforms poll very poorly with the American public.

However, it’s not the changes to Medicare that constitute the biggest changes. Ezra Klein explains:

“If you look at the numbers Ryan gave to the Congressional Budget Office, the cuts to Medicare are only 60 percent as large as the cuts to Medicaid and other health-care programs. And the cuts to Medicaid and other health-care programs are only half as large as the cuts to non-entitlement programs.”

The figures reflect America’s complex relationship with government run health care. Even conservatives overwhelmingly support some entitlement programs; “get your government hands off my Medicare” become an often heard cry at Tea Party rallies. But you never hear the same passionate defence of Medicaid from anyone the right. Even though the cuts to this program are substantially bigger it won’t get a tenth of the political attention.

One explanation for this disparity jumps out. Medicare is a program for everyone 65 and older while Medicaid is for low income individuals closer to the margins of society. The elderly are a key political demographic with a lot of electoral clout.

Citizens also often view entitlement programs that benefit them as essential while those that don’t as wasteful government spending. Nearly everyone has elderly friends or relatives and can envision themselves getting older as well. But programs targeted at the poor can feel a lot more distant.

In the wake of Obamacare many Republican governors announced that even with the federal government picking up over 90 per cent of the costs they would still reject the Medicaid expansion. Texas governor Rick Perry called Medicaid a "failed program" and that enlarging it would be tantamount to adding "1,000 people to the Titanic." Whatever you think of Perry's rhetoric it's clear that he would have chosen his words quite differently if the benefits were targeted at the elderly.

This is a bit of an overshare. It’s the kind of thing that would usually be private. Unfortunately, by co-sponsoring HR 212, Paul Ryan has made my private health issue a matter of public policy.

I have Polycystic Ovarian Syndrome. It’s pretty sucky. Basically, it means that I have a hormonal imbalance that does all sorts of really unfortunate things to my body — acne, extra hair, weight gain. On top of that, I get my period really rarely. Like, maybe three times a year. That may sound alright (the fewer periods the better, am I right ladies?), but when I do get them, I have incredible amounts of pain. Plus, and this is more important to me, my chances of getting pregnant naturally are pretty tiny.

One of the problems with getting a period so rarely (which is actually a condition called oligomenorrhea) is that it puts you at a higher risk of getting uterine cancer. So on top of all the rest of the horribleness that is PCOS, you are at a higher risk of cancer.

PCOS is pretty common. It’s estimated that between 5 and 10 per cent of women of reproductive age have it. It’s the most common endocrine disorder for women in that age bracket. It’s also incurable.

One of the most common and effective treatments of the side-effects of PCOS is the Pill. It treats a bunch of the symptoms. My skin clears up. I lose weight. But, more importantly, I get my period regularly, which means it hurts less and, best of all, reduces my chance of getting endometrial cancer.

But Republican VP candidate Paul Ryan doesn’t care about any of that. He doesn’t care about preventing pain or reducing the risk of cancer. He wants to ban the oral conceptive pill because he thinks a fertilised egg should have all the protections of a human being.

You can see how ridiculous this is in my case. He would ban me from being able to access medical care I need because of a potential fertilised egg. The fertilised egg doesn’t even exist. The fertilised egg has a very slim chance of ever existing naturally, due to my PCOS. But he’s so concerned about that potential, he’d prevent me from having access to the care I need.

And you know what? If I did want to have a kid, he’d like to sincerely limit my options there too, because he’d ban IVF.

Paul Ryan is an extremist. For all the talk about small government, he’d like to interfere with my doctor’s capacity to treat my chronic condition. That’s about as big as government gets.

AMC's super-hyped drama Breaking Bad returns to air today — or, more accurately, Sunday evening US time. Max Rivlin-Nadler argues that the show depicts a "failed American Dream":

There are many sources to assign blame for Walt's sorry condition. As a teacher, Walter shouldn't have to take a second job just to provide for his family—it's even hinted that the fumes from the car wash were the catalyst for his cancer. As a citizen, he shouldn't have had to decide between cancer treatment and the well-being of his family (but privatized healthcare will do that to you). People usually deal with these obstacles legally. They do so by racking up more debt, burdening their families, placing more people in the red in states that vote deep red. But Walt resists. He uses whatever agency he has to die on his own terms. Because the stakes of drug trafficking firmly places our protagonist so far outside the status quo, because our hero is a criminal, the viewer is forced to ask, If playing by the rules only gets you so far, why bother? Breaking Bad dismisses the idea that your blue-collar job will provide for you, that, if needed, the State will, too, and that doing the right thing will be its own substantive reward. The show doesn't aim to moralize or assign blame; it works to deconstruct these little fallacies that keep the poor from demanding dignity.

If The Wire was the great television drama of the Bush years, Breaking Bad feels particularly suited to the post–Great Recession Obama term. Its first season aired during the final twelve months of the Bush administration, and as Democratic candidates were debating the necessity of reforming the American health care system, on the show, high school science teacher Walter White was being pushed into drug dealing because his insurance wouldn't cover his cancer treatments. Walt's misery and emasculation throughout the series derives from a sense that America no longer functions as a meritocracy. At the beginning of the show, Walt works two jobs, both of which he's overqualified for, because years ago he was pushed out of the massively successful tech business he co-founded back in grad school. Despite his great talent at chemistry, he only find success when he drops out of society and starts manufacturing methamphetamine. In Breaking Bad's America, the only people who get ahead are the ones who don't play by the rules.

After the jump, I've reproduced a post I wrote earlier in the year about the show's relationship with its Southwestern setting.

The Great American Television Dramas of the 21st Century each took on the city in their own way. The Wire, most famously, pieced together a Baltimore characterised by multivalency, a blown out, concrete place where nothing is discrete: all the pieces matter. The Sopranos deliberately swerved away from the city like Tony does in the opening credits, relocating the mob drama from its inner Manhattan, Little Italy origins to the capillaries of calm suburbia spreading out beyond, permanently removed from, and economically reliant upon a thumping New York heart.

“Mad Men” is also a New York show, and at that a suburban one, but where the drama of The Sopranos occurred in the volatile outdoors — the parkways and Pine Barrens and parking lots, and the café tables outside Satriale’s — Mad Men’s world is an insular one; exterior shots are few and far between, and the characters seem to transition from home to office to restaurant to bar without needing to venture out in to the wider world. There are no shots of skyscrapers or city lights, downtown traffic jams or subway entrances. The story in its entirety exists in an artificially-lit, hermetically sealed otherworld, one fitting the hyper-reality of protagonist Don Draper’s advertising trade.

In Breaking Bad, Albuquerque is an oasis and a mirage. The show’s hero (of sorts), Walter White, lives in a small, flat, indistinct bungalow in a neat suburbia — but it’s a suburb distinguished not by the moneyed grandeur of Tony Soprano’s neighborhood, but in the American 20th century pioneer's modest ambition that even a high school teacher should be able to carve out his own free-standing, self-contained refuge from the hurley burley of city life. Walt’s partner-in-crime, Jesse Pinkman, at first lives even farther removed from the urban and the natural environments surrounding him; his neighborhood is characterized by verdant lawns and lush foliage, a pocket of every-America in a mountainous desert state.

The Western was about the arrival of civilisation to the frontier, but Breaking Bad is a post-Western; it narrates the return of the savage. The brusque desert is never far from Walt and Jesse’s subdued suburbia; it’s where they cook the meth that makes them rich, in a dilapidated recreational vehicle parked in the flat, alien wasteland off I-40, the trail connecting Albuquerque to the wider Southwest. The scenes shot out here, far from the moderate residential regions, are blankly beautiful: flat yellow prairie, blue sky, and, every now and then, a stretch of red mountain in the distance; a furnace, a cauldron, a place to cook.

The crystal meth they produce out in that moonscape comes back to Albuquerque, and so does the desert. The city can’t keep it out. Walt’s home is decorated in warm earthtones: golds and browns, offset — like the sky above the desert — with brilliant blues. Walt’s brother-in-law Hank, the DEA agent, is even closer to the desert, just like he’s (as far as most people know) even closer to the drug trade: Hank lives in an adobe home, that Southwestern style patterned after the pueblo constructions of the region’s Native Americans. High on a mountain, he looks out over the city, and the desert in which it sits — and where Walt cooks.

The drugs Walt cooks are sold in small pockets of a city where everything is fractured. Albuquerque is a town of crystals — yes, pun intended. In The Wire, everything is linked to something; in Breaking Bad, everywhere is nowhere. A gas station, a seedy motel, a franchise of a fast food chicken chain, a vacant lot, a junkyard, a strip mall legal firm’s storefront, the wide empty streets connecting them: all united only in that all are dissociated. Even Albuquerque’s downtown is squat and modest; the most prominent scenes here take place in the anonymity of a federal government building.

In Breaking Bad, Albuquerque is a city whose triumph is its ordinariness, and its existential threat is the blank amorality of the desert creeping back into town.

On average, the federal government pays 57 per cent of the costs of the Medicaid program in which your state currently participates. The federal government will be picking up over 90 per cent of the costs of the expansion. You’ve never previously considered opting out of Medicaid entirely. Why are you now refusing to implement an expansion of the program in which you’ll be picking up a much smaller percentage of the costs?

To summarise a point made by Josh Barro, is government health insurance for your state’s working poor really so “undesirable” that you’re not willing “to pay ten cents on the dollar for it"?

Most analysts predicted that if Chief Justice Roberts voted with the majority, it would be for a 6–3 ruling. Instead, he was the key vote to uphold, and Justice Kennedy was the one prepared to overturn the entire bill.

Either way, this was going to be a 5–4 decision. Roberts could easily have voted to overturn. That he did not suggests he really does care about maintaining continuity with previous rulings, preserving the Court's credibility in the eyes of the American people and protecting its status as an institution above the disputes of day-to-day partisan politics.

Roberts may today have proved that court is not as extreme as many of its critics fear — see, for instance, this recent post by James Fallows at American Review. But perhaps Anthony Kennedy is. He voted to end the recount in Bush v. Gore, was the driving force in expanding the scope of Citizens United v Federal Election Commission, and was now willing to declare the entirety of the Affordable Care Act unconstitutional. He's less the court's moderate and more its highly volatile extremist.

Roberts's vote to uphold the individual mandate on the basis of the commerce clause but on Congress's power of taxation is novel, and could lead to greater ramifications later on. Is this limit on the commerce clause going to lead to meaningful restrictions on what Congress does in the future, or, is, as Brad Plumer suggests, health care such an exceptional market that the limits Roberts has set in place will apply to few other situations?

I said last night that leaks from the Supreme Court are rare and DC is filled with people who like to look like they have some insider information. I should have added that colleagues of the guy who argued the case against the government might indeed have insider info. When he was here at the Centre last month, Professor Larry Gostin said his Georgetown colleague Paul Clement had advised to watch out for the Medicaid expansion as a sleeper issue. A pointer worth heeding, it turns out.

The ruling on the Medicaid expansion does indeed seem to be the part of the judgement with the biggest ramifications. If the federal government can offer money to encourage the states to implement a program, but can't coerce them by threatening to withhold funding. For instance, does this affect the National Minimum Drinking Age Act, which requires states to set their legal drinking age at 21 or lose highway funding? (The court ruled this constitutional in South Dakota v. Dole.)

Sarah Kliff: "If you read the opinions, [Roberts] sided with the conservative bloc on every major legal question before the court." Obamacare stands, but a lot of constitutional questions that were once considered settled are now back up in the air. In some ways, this ruling is a twin of the Court's decision in District of Columbia v. Heller, which made a major constitutional revision through an exceedingly minimal change. (There, the ruling was only that the District of Columbia couldn't entirely ban all private ownership of handguns — but that overturned a long established precedent that the second amendment did not confer an individual right.)

By, in effect, declaring the individual mandate to be a tax, has Roberts made it easier for a future Republican congress to repeal the law? After all, while a requirement to purchase health insurance may not be a budgetary action, a tax on not having health insurance definitely is. Repealing that tax should fit comfortably within the realm of any filibuster-proof reconciliation bill that Republicans bring before the Senate if they win a majority in that chamber this November.

Republicans have picked up quickly on the "tax" aspect of the ruling. RedState has already started to refer to the mandate as Obamatax. New Jersey govenor Chris Christie tweeted, "Most importantly, the Supreme Court is confirming what we knew all along about this law – it is a tax on middle class Americans." Criticising Democrats over taxes is comfortable territory for Republicans, but I'm not persuaded that calling an unpopular mandate a tax offers the GOP any political advantage it didn't already have.

Sarah Palin has spearheaded a popular meme that the "tax" finding means Obama "lied." Jennifer Rubin has the same message, but pretties up the language a bit: "while the Obama administration swore up and down that Obamacare did not tax every American, the Supreme Court, in effect, held that the Democrats did exactly that. In that regard, the opinion is a tribute to President Obama’s utter disingenuousness."

In the meantime, following Obama’s lead on illegal aliens, I think Mitt Romney should declare that if he is President he’ll seek “prosecutorial discretion” to not go after people who don’t pay their individual mandate tax.

Settle down! As it was passed, the bill has no provision to "go after" people who don't pay the penalty. For all the talk of the individual mandate being such a draconian provision, it has no enforcement mechanism, and no one is going to be sent to prison by the IRS if they don't pay it.

To any Americans who want to prep themselves for the inevitable government mandate that all citizens eat broccoli, may I suggest Seattle's Black Bottle tavern? Best broccoli I've ever had.

...Here's my prediction on the outcome of the Supreme Court's ruling on Obamacare, due in a few hours:

I have no idea.

The Supreme Court keeps its secrets closely guarded and Washington is a town filled with people who like to look like they have insider info. Good predictions come from close observation and long experience, but sometimes the most accurate prognostication is to admit that, lacking telepathic abilities, I don't have a clue. I will be surprised. I will make no claim to bragging rights.

In early February Mitt Romney stirred up a bit of controversy with his comment that “I’m not concerned about the very poor. We have a safety net there.” Romney caught a lot of flak for his remark, but the gaffe could become oddly descriptive of the American healthcare system if the individual mandate gets struck down but the rest of the law is upheld.

The Affordable Care Act requires insurers to offer a certain baseline package and prohibits them from discriminating against those with pre-existing conditions. However, this sort of regulation creates an adverse selection problem with sick people rushing to buy insurance and healthier individuals opting out of the system and driving up premiums. The goal of the mandate is to bring healthy people into the insurance market in order to bring down the costs of insurance. If the Court strikes down the mandate it’s unclear whether the system can still work, as many health experts believe that the cost of insurance would go through the roof. If that’s the case, many aspects of the law would need to be revised and the ambitions of the bill scaled down.

However, the ACA also extends coverage through an unrelated expansion of the Medicaid program. Previously, Medicaid was a means tested program available to select groups below the federal poverty level. Under the ACA, everyone up to 133 per cent of the FPL is now eligible.

There’s a possibility that this part of the law could get struck down as well. Medicaid is jointly funded at the state and federal level with states opting into the system under the agreement that they spend federal funds as directed. Under the ACA, the federal government is at first providing all of the funding to cover new Medicaid recipients and then will transition to a system where states pick up 10 per cent of the tab.

Some states have argued the system is unfairly coercive, claiming that they almost have to agree to the new terms given how much they stand to lose by dropping out of the Medicaid system. Still, I’d be pretty surprised if the Court accepted this argument. It’s hard to see how it’s unfairly coercive for a parent to offer to pay 90 per cent of their daughter’s college tuition provided she covers the rest. Tellingly, none of the lower courts have found the Medicaid expansion unconstitutional.*

So if the Court were to strike down the individual mandate but leave the rest of the law intact, where it would leave us? All individuals up to 133 per cent of the poverty line would be insured. Those over 65 would be insured through Medicare. Those who are rich will in most cases be able to get insurance regardless. Those left in limbo will be lower and middle class Americans.

I would never wish upon anyone the hardship and uncertainty that comes with living near the poverty line. These Americans face challenges that few can even begin to understand. It’s interesting though that this group may end up with more security when it comes to healthcare than many Americans who are more economically well off. The ACA will likely create a more comprehensive insurance program for poorer Americans, but in the end it could have much less to offer others facing the continued squeeze of rising healthcare costs.

*Still, health policy expert Larry Gostin did say while at the US Studies Centre that conservative superlawyer Paul Clement told him that the Medicaid expansion could be the sleeper argument.

In February I did a summary of the lengthy journey from bill to law of the Affordable Care Act also informally know as Obamacare. Here, I’m going to explore what the law actually does. This is not intended to be a comprehensive analysis of the nearly 1 000 pages of legislation, but rather a foundation for understanding the major aspects of the ACA.

If you’re looking for a more in depth look at the American health care system, I’d highly recommend Introduction to U.S. Health Care Policy by Donald A. Barr. I frequently cite the 2011 edition of the book in this post. If you have any questions about this post or health care policy in general, feel free to post them in the comment section or under the Ask Uncle Sam feature of the Election Watch website.

As its name suggests, the Affordable Care Act was designed to extend health insurance to 32 million Americans by making coverage more affordable. The ACA doesn’t get rid of the private health insurance market, but it does implement changes in the way it operates and also allows more people to obtain coverage through the government run Medicaid program. The law can be divided into three major parts: 1. Regulations on the insurance market intended to increase the availability of health insurance plans; 2. An individual mandate designed to make these regulations work; 3. Subsidies to help people with “lower incomes” afford the cost of insurance premiums. I’ll deal with these topics one at a time.

The Affordable Care Act seeks to expand private health insurance coverage in several ways. Most notably, all insurance companies must “offer the same premiums to all applicants of the same age and geographical location,” regardless of their health status. This is a dramatic departure from the previous system in which insurers would often charge those with pre-existing conditions substantially higher rates, or in many cases deny them coverage altogether.

Beginning in 2014, companies with over 50 employees will be required to offer health insurance coverage to their workers or else pay a tax penalty . To facilitate access to insurance for those who do not receive it through work, states are required to set up health insurance exchanges in which consumers can compare plans. Plans offered through these exchanges must provide a baseline set of benefits, and each exchange must offer at least two competing plans, one of which is provided by a non-profit organisation. These plans must also offer four “predefined level of benefits".

The goal of the exchanges is to create a transparent one stop destination for small businesses and individuals who don’t obtain coverage through their employer to shop for health insurance, and to encourage market competition between insurance companies within a regulatory framework that ensures that they offer coverage to anyone who needs it.

The ACA also expands the scope of Medicaid, the government run health insurance program that is financed by a combination of federal and state funds and administered by the individual states. Traditionally, Medicaid has been available to all children (and some parents) whose family income is below the poverty line, some pregnant women, the disabled, and seniors at a designated level below the poverty line. Citizens over 65 already receive health benefits through Medicare. Under the new law, all individuals and families with incomes below 133 per cent of the poverty line will be eligible for Medicaid. These changes are expected to extend coverage to 16 million previously uninsured Americans.

Prohibiting private insurers from discriminating against high risk applicants poses challenges though. Charging healthy and unhealthy individuals the same insurance rates creates an adverse selection problem; the sick will rush into the system while the healthy will choose to opt out. If I can purchase insurance at the same price once I get sick, it is rational to wait until I fall ill to buy it. Insurance works by pooling together the risk of individuals, but under the given rules, the pool will be flooded with high risk and expensive consumers. Since the per capita health expenditures within pools will be high, so too will the premiums that consumers pay. In order for these new regulations to work, there needs to be a way of bringing younger and healthier individuals into the risk pool.

This is where the individual mandate comes in. Under the ACA the uninsured -with the exception of select groups such as religious objectors-will be required to purchase a baseline level of health insurance coverage or pay an annual penalty of $695, or 2.5 per cent of annual income, whichever is greater. The penalty is not high enough to create de facto compliance, so it is anticipated that even with the mandate a fair number individuals will choose to opt out of coverage.

The federal government will also offer new subsidies to help offset the cost of purchasing health care. People who are above the cut off line for Medicaid but whose income is less than four times the poverty level will be eligible for subsidies. Federal funding is provided on a sliding scale. Individuals and families with incomes 3 to 4 times the poverty level would not have to pay more than 9.5 per cent of their income for insurance, while those closer to the federal poverty level would not pay more than 3 to 4 per cent.

Additionally, some small businesses that pay over 50 per cent of their workers health insurance costs will be eligible for tax credits.

In sum, the ACA attempts to address the affordability of health care by increasing the number of people eligible for Medicaid, preventing insurers from discriminating against those with pre-existing conditions, and increasing federal subsidies to low and middle income Americans.

The costs of the new healthcare program are financed in a number of ways. Most notably, is an additional 0.9 per cent payroll tax on individuals with an annual income over $200 000. Similarly, there is a 3.8 per cent tax on passive income, such as investments or royalties, that totals over $200 000 in a year. These taxes fund the Medicare program that provides health coverage to Americans over 65.

There is also a new excise tax on “group insurers with annual premium payments in excess of $10 200 for individual coverage and $27 500 for families.” The tax rate is “40 percent on the amount of premiums above the thresholds”

Additionally, the ACA imposes a variety of smaller fees on the “health care industry.” Among these are a 2.3 per cent tax on infrequently purchased medical devices , taxes on pay for health care executives whose companies fail to meet given government guidelines, and an annual tax on “certain manufacturers and importers of brand name pharmaceuticals.” You can peruse the links I’ve provided if you’re interested in a fully comprehensive list of the funding mechanisms for the ACA. And here’s a good pie chart on how the bill is financed.

Estimating the total costs of the bill is not exactly a straightforward task because individuals disagree over the mechanisms used and in part because politically motivated individuals on both sides are excellent at obfuscating the issue. The Wikipedia article on the ACA provides a good summary of these areas of disagreement.

The nonpartisan Congressional Budget Office which is responsible for scoring the costs of legislation estimated in March 2011 that the act will bring in $813 billion from 2012 to2021 and cost $613 billion to implement, resulting in a deficit reduction of $210 billion dollars. At the time it was passed into law the CBO projected that the ACA will cause “national health... expenditures to rise to 19.6 percent of GDP (by 2019) as compared to 19.3 percent had ACA not been enacted.”

There’s also a final point aspect of the health care bill worth touching on. As Sarah Kliff explains:

“much of the law’s 905 pages are dedicated to... an overhaul of America’s business model for medicine. It includes 45 changes to how doctors deliver health care — and how patients pay for it. These reforms, if successful, will move the country’s health system away from one that pays for volume and toward one that pays for value. "

I’d like to tackle the issue of cost controls on health expenditures in a later post. It’s an extremely important topic, but also a pretty wonky one. A lot of the new regulations focus on incentivizing efficiency and encouraging health care providers and insurers to keep costs down (such as the previously mentioned tax on expensive health care plans. Ezra Klein points out that the bill implants a wide variety of potential cost control mechanisms attempting to make “reform a continuous, rather than occasional, process.”

One area of agreement amongst both defenders and critics is that, even if the ACA is upheld by the Supreme Court, this will not be the end of the health care reform process. Simply put, while the law begins to address rising medical costs, it doesn’t contain the sort of large scale cost control mechanisms that will curb the continuously increasing expenditures on health care. The ACA is not the cure-all for a troubled health care system, but is it an important step in the right direction or a journey down the wrong path?

Something for the weekend: Luke and I have put together a brand new podcast for you guys. This week we're talking about the Trayvon Martin case and the Supreme Court's consideration of the Affordable Care Act. Listen in the widget below!

Tuesday's oral arguments were a cruel two hours for the Obama adminstration and supporters of the health care bill. The four key votes in the case, Chief Justice Roberts and Justices Alito, Scalia, and Kennedy, seemed all too willing to accept the petitioner’s claim that the individual mandate represents an unprecedented and troublesome expansion in governmental power. At the start of the day, numerous legal experts believed that the Obama administration's arguments would prevail easily; now, all bets are off.

An especially interesting wrinkle in the case has always been Justice Kennedy and Justice Scalia's embrace of broad federal powers in Gonzales v. Raich. In the 2005 case, which in many ways parallels the one currently before the Court, the two Justices joined the more liberal wing of the Court in ruling that Congress had sufficient power under the Commerce Clause to prohibit individuals from growing medicinal marijuana for private consumption.

Liberals hoped that this ruling might compel even the very conservative Justice Scalia to uphold the law. Unfortunately for them, that no longer appears likely. Undeterred by the spectre of Raich, Scalia all but announced in oral arguments that he was going to vote to strike down the indvidual mandate.

Reading the tea leaves in these cases is often a fruitless task, but, since I couldn't resist, I went over the transcript from Gonzales vRaich and compared the two Justice's statements from oral arguments to the votes they ultimately ended up casting. If Justice Kennedy-or perhas even Justice Scalia-appeared sceptical of the constitutionality of the law but eventually upheld it, perhaps they might do the same thing in the current health care case.

Despite ultimately siding with the federal government, Scalia did draw attention to several perceived holes in their argument.

“I mean, in these other... in these other cases, Congress presumably wanted to foster interstate commerce in wheat, in Wickard v. Filburn. Congress doesn't want interstate commerce in marijuana. And it seems rather ironic to appeal to the fact that home-grown marijuana would reduce the interstate commerce that you don't want to occur in order to regulate it. I mean, you know, doesn't that strike you as strange?”

However, far from contradicting his vote in the case, Justice Scalia's line of questioning actually makes a lot of sense given the concurring opinion he ended up writing. While Justice Stevens's majority opinion relied heavily on rationale of Wickard v. Filburn, Justice Scalia's concurrence focused more exclusively on the Necessary and Proper clause. In this context, it seems doubtful that Scalia had a change of heart between oral arguments and voting, but rather that he was trying to convince the other Justices of his own rationale for upholding the government's regulation.

At numerous other points, Justice Scalia appeared outwardly supportive of the federal government's position. He mentioned that the prohibition of marijuana appeared similar to an existing prohibition on the possession of endangered eagle feathers. In that instance, Congress had explained that there was no way of determining whether the feathers came through interstate commerce or not. Obamacare supporters who still cling to the irrational hope that Justice Scalia might uphold the mandate probably won’t take much solace in the oral arguments from Raich. Justice Scalia showed a sympathy for the Bush administration’s argument that was wholly absent from his line of questioning in the health care case.

Justice Kennedy was coyer. Many of his comments in Raich were clarifying questions, asking the lawyers to expand on statements they had made. But, the few viewpoints he did express offered cautious support for the federal government's position. Once, he reminded Bush’s Solicitor General of a case that would support their argument. He also hinted several times that the mere possession of marijuana might constitute economic activity, and that its "fungibility" made it difficult to establish whether it came through interstate commerce or not.

Kennedy voiced concern on Tuesday that the individual mandate could justify a whole host of new federal powers, but he never expressed similar worries over allowing the federal government to regulate private marijuana use within the home. All indications are that he sees the Obama adminstration's argument in the current case as at least somewhat weaker than the Bush's administration's argument for a blanket prohibition on marijuana. In Justice Kennedy’s eyes, Raich may be more or less in line with traditional congressional regulation of economic activity, while Obamacare is an unprecedented use of Commerce Clause power.

Of course, none of this means that Justice Kennedy is a sure bet to strike down Obamacare, only that he sees it representing a somewhat troubling intrusion on indvidual autonomy and state sovereignty I could see Justice Kennedy going either way. He obviously seems troubled by the idea of government mandates, but, as others have pointed out, the outcome of the case might well hinge on whether he thinks he can uphold the law and still identify clear limiting principles that would restrain the government in the future.

The Supreme Court has now heard two days of oral argument on whether the Affordable Care Act is constitutional, and experts are inferring, from the thrust of the justices' questioning, that the outlook for Obama's signature reform is grim. Here's Sarah Kliff, for instance:

Going into Tuesday morning’s Supreme Court arguments, there was decently widespread agreement that the health reform law’s mandated purchase of insurance would survive the Court’s questioning. One poll released Monday, of 69 former Supreme Court clerks and attorneys who had argued there, found that 65 percent expected the provision to be upheld. On InTrade, odds hovered just about 67 percent.

But when the Court let out after two hours of oral arguments on the individual mandate, observers seemed a lot less certain. Jeffrey Toobin told CNN that he thought the arguments were a “trainwreck” for the administration, predicting now that the provision would get struck down. Donald Verrilli, who represented the Obama administration, stumbled over his words in his opening statement while Paul Clement, representing the law’s opponents, delivered a strong performance. On InTrade, the odds of the mandate being overturned shot up to 55 percent.

Certainly the court seemed far more hostile to the individual mandate than observers expected — particularly the court's conservative judges, whom many observers expected to take a reticent stance based on precedent and a desire not to extend the court's reach too far into contemporary political debate.

But what if the day's arguments didn't matter that much? Jeffrey Toobin suggested to Ezra Klein that, in general, oral argument is not particularly important to the outcome of a case:

"Most Justices say their minds are changed by oral arguments a handful of times — fewer than five — per year," he e-mailed. "In my experience, the higher profile the case, the less oral arguments matter, because the Justices have strong and longstanding views about major constitutional issues. The Justices mostly use oral argument to talk to, and lobby, each other, through their questions to the lawyers." In other words: The minds the justices are looking to change may not be their own.

Further, Jonathan Bernstein cautions against getting too confident with predictions either way, and Lyle Denniston proposed that not much has changed from before the Court heard the arguments:

If Justice Anthony M. Kennedy can locate a limiting principle in the federal government’s defense of the new individual health insurance mandate, or can think of one on his own, the mandate may well survive. If he does, he may take Chief Justice John G. Roberts, Jr., and a majority along with him. But if he does not, the mandate is gone. That is where Tuesday’s argument wound up — with Kennedy, after first displaying a very deep skepticism, leaving the impression that he might yet be the mandate’s savior.

Meanwhile, Mike Barthel thinks the politics will end up being far more important than the constitutional questions:

[T]he case you want to look to here, it seems to me, is Bush v. Gore. That case was decided on explicitly partisan grounds. The court came up with some legal logic, but then at the end of the decision they said that they weren’t establishing a principle and no one should apply this logic to any other case. They just sorta waved their hands and said “Hey, we wanted to decide this case this way, but we couldn’t really justify it, so we just decided it that way anyway and never mind why.”

The same thing is likely to happen here, I think. Of course Congress has the authority to tell everyone they have to do something. Even before reform, the health care industry in America was already so highly regulated that it looked like a Soviet grain production scheme. And the Court doesn’t have any interest in overturning that principle, not only because it would cause chaos, but because it would lessen their own authority. (The law that gives administrative agencies power to set regulation also gives federal courts the ability to adjudicate them; it’s the balance-of-powers equivalent of voting yourself a pay raise.)

And so, if they do overturn it, it’s going to be an incredibly narrow and nakedly partisan ruling.

If you haven’t already noticed, the topic of health care comes up a lot on the campaign trail. Like, all the time; seriously you’re going to be so tired of hearing about it by November. Since this issue isn’t going away anytime soon, it’s worth devoting a little time to understanding The Patient Protection and Affordable Care Act (PPACA) or “Obamacare.”

In the first of a two part series, I’m going to review the bill’s long and eventful journey in becoming law. In the second part, I’ll go into detail as to what health care reform actually does. As Otto Von Bismarck famously proclaimed, “If you like laws and sausages, you should never watch either one being made.” If you agree with Bismarck’s sentiment, it’s best to stop reading now.

Harry Truman was the first American president to formally propose a universal health care system and move the issue into the forefront of the American political debate. Although his plan gained little traction in 1945, Democrats have remained committed to comprehensive health care reform, and every Democratic president since Truman has expressed support for universal health care.

Both Barack Obama and Hilary Clinton made universal health care a key issue in their 2008 presidential primary campaigns. Unlike Clinton, Obama was opposed to requiring individuals to purchase insurance as a means of broadening the risk pool and decreasing health insurance premiums, “well, if things were that easy, I could mandate everybody to buy a house, and that would solve the problem of homelessness. It doesn't.” Ironically, the “individual mandate” ended up being the centre piece of the health care reform bill.

Upon taking office, Obama put health care reform at the top of his legislative agenda. The goal was to help curb the rising cost of health care, expand coverage to the uninsured, and prevent insurers from denying coverage to those with pre-existing conditions. Both Republicans and Democrats generally agreed that these issues eventually needed to be addressed, although there was wide disagreement over the best means of doing so.

With large majorities in both chambers of Congress and the support of President Obama, Democrats were optimistic that they could pass comprehensive health care reform. However, their plans hit an initial roadblock in February 2009 when former Senator Tom Daschle withdrew his nomination as secretary of health and human services amid revelations that he had not properly reported or paid his income taxes. Before the scandal, Daschle had been set to lead the Obama’s administration’s health care overhaul.

Initially, Obama took a passive role in the health care reform process, outlining his broad goals but allowing Congress to try and work out the details of the plan. In May 2009, Speaker of the House Nancy Pelosi vowed to have the bill signed into law by August. However, things didn’t go exactly according to plan for the Democrats. At town hall meetings across the country citizens protested against the proposed bill, and Republican lawmakers warned of the dangers of “socialised medicine” and “rationing health care.”

Democrats also had trouble convincing the more moderate members of their coalition to sign onto the legislation. In the 2006 and 2008 elections, Democrats won a large number of seats in generally conservative congressional districts. While this was obviously good news for the party, many of these new members of Congress were very moderate. These “Blue Dog Democrats” were concerned about the costs of health care reform and were reluctant to endorse government rune insurance plans. Bills have to pass through relevant committees before they can proceed to the floor for a vote, and Democrats had to appease the demands of many House Blue Dogs in order to get the bill through committee. Democrats informed Obama that passage of the bill could take longer than anticipated.

There was also much controversy surrounding the issue of abortion. The 1976 Hyde amendment prohibits federal funds from being used to pay for abortions, but there was dispute over what this should mean in the context of publicly subsidized health care. Eventually, House Democrats agreed to adopt the Stupak amendment, a proposal by Michigan congressman Bart Stupak stipulating that no federal funds be used to cover any part of a health care plan that covered abortion. Many pro-choice Democrats were upset at the compromise, but the amendment ultimately secured the necessary votes for the bill’s passage.

On November 7 2009, the Affordable Health Care for America Act was passed by the House of Representatives by a narrow margin of 220-215. Only one Republican voted in favour of the bill and 39 Democrats voted against it. The bill included a government run insurance plan, or public option, that would compete against the plans offered by private insurers. The bill mandated that all citizens buy insurance or a pay fee, and provided government subsidies to those who could not afford insurance on their own. The bill would cost $1 trillion dollars and would extend health insurance coverage to 36 million Americans.

Progress in the Senate was also very extremely slow. Senate rules required 60 votes to prevent Republicans from “filibustering”, blocking the bill from proceeding to the Senate floor for a vote. This meant that Senate Majority leader Harry Reid needed to get all 60 members of the Senate Democratic caucus to sign onto the bill. In order to appease moderate Democrats, various versions of the House bill needed to be modified. On December 24, the bill was finally passed along a strict party lines vote (60-39). It would cost $871 billion over ten years, and, notably, did not include a public option. The language regarding abortion was different as well. People receiving federal subsidies could buy health plans that covered abortion, but they had to write a separate monthly cheque for abortion coverage.

The final task was to merge the two bills into one. While there was still work to be done, it seemed fairly inevitable that the Affordable Care Act would become law. Then, the unthinkable happened. On 29 January 2010, Republican Scott Brown won the Massachusetts Senate special election to fill the seat of the late liberal icon Ted Kennedy, who had died that past August. Democrats now lacked the 60 votes to override a filibuster, meaning they could not pass a modified version of the health care bill. Massachusetts had no Republican representatives in Congress, and hadn’t elected a Republican Senator since 1972. Ted Kennedy had called universal health care “the cause of his life,” but now reform appeared in jeopardy because Democrats couldn’t hold onto his seat in one of the most liberal states in the union. In the eyes of many, this was the end of the road for health care reform. Others Democrats wanted to abandon their ambition for sweeping reform, and instead try to pass much more moderate legislation.

However, key members of the party continued to explore other options for passing the bill. Obama also refused to back down on the issue, emphasizing that Democrats couldn’t give up now after coming so close to their goal.Eventually, Senate Democrats settled on a potential solution: “reconciliation.” Reconciliation is a process generally used to modify spending in bills for the purpose of deficit reduction, and requires a simple up or down vote instead of the 60 votes required to end a filibuster. The Senate couldn’t pass an entirely new bill through reconciliation, but they could make small budget related changes to the bill they had already passed in December.

In late February, Obama and Pelosi announced that they supported using reconciliation in order to get the bill through Congress. Democrats argued that they were justified in using the procedure because given that the bill was projected to reduce deficits, it could be considered a deficit reduction measure. They also pointed out that Republicans had previously used reconciliation to pass several major pieces of legislation. Republicans accused Democrats of using a loophole to get an unpopular piece of legislation through Congress.

Speaker Pelosi was clear that she did not have the votes to simply pass the Senate Bill in its exact current form, given that House members had concerns with some specific provisions. Most notable was a guarantee that Nebraska would not have to pay any of the costs associated with the health care bill’s expansion of Medicaid. Senate Majority Leader Harry Reid had offered this deal in order to convince Senator Ben Nelson from Nebraska to vote for the legislation. Senate Democrats agreed to amend these provisions through reconciliation.

Still, there was much work to be done. Speaker Pelosi had gotten House Democrats to already sign off on one bill; now she had to persuade them to pass a bill nearly identical to the one that the Senate had already approved. Many liberal Democrats were frustrated that the Senate bill was less comprehensive than the one they had passed, but they realized that at this point it was their only option. The real difficulty for Pelosi was winning over moderate, and especially, pro-life Democrats. The Stupak amendment had been essential in getting the support of around 40 members of Congress the first time around, but there could be no such provision in the final bill. The White House and House leadership worked with these pro-life Democrats to try and find an acceptable compromise.

Then, on the evening of 21 March, Congressman Stupak and a number of other pro-life Democrats announced they had reached an agreement with the Obama administration. Obama would issue an executive order reaffirming the government’s commitment to the Hyde Amendment and also address some of the Stupak coalition’s other minor concerns, such as clear abortion restrictions on government sponsored community health clinics.

Later that evening, the House of Representatives passed the Patient Protection and Affordable Care Act by a vote of 219-212. Every Republican and 34 Democrats voted against the bill. On 23 March, Obama signed the bill into law, proclaiming that health care reform reflects, “the core principle that everybody should have some basic security when it comes to their health care." Attorney General’s in 13 states immediately filed lawsuits claiming that the bill’s individual health care mandate was an unconstitutional violation of federal powers. Two days later, the Senate passed the reconciliation bill to amend the health care legislation in accordance with the stated wishes of the House. The reconciliation bill passed the Senate by a vote of 56 to 43. Senator Nelson was amongst three Democrats who voted against the bill. The process had been a long and often frustrating one, but Democrats had finally achieved the goal that had so long eluded them.

On January 20, the White House announced that nearly all employer-provided health insurance plans must entirely cover the cost of contraceptives for women. The administration determined that only religious institutions that primarily served members of their own faith would be exempt from the law. In other words, a church would receive an exemption but a Catholic hospital would not. The requirement was widely hailed by liberals, but I have reservations about the way the Obama administration handled the decision.

Don’t get me wrong, access to birth control is an essential aspect of female autonomy. But, the administration was too quickly dismissive of another liberal value, religious freedom. The Catholic Church is officially opposed to the use of contraceptives and requiring Catholic hospitals or universities to cover the cost of birth control for their employers is to ask them to violate their teachings.

One could argue that it’s only fair that religious groups be treated like anyone else when they employ and serve Americans of all different faiths and backgrounds. However, one of the virtues of American liberalism is its willingness to try and accommodate the diverse religious beliefs and values of its citizenry. Religious liberty means not just protecting rights in the private sphere, but trying to find flexible solutions for respecting freedom of conscience in public life as well. The Church has long been a firm proponent of social justice, and Catholic hospitals and charities are now in effect being told that upholding this tenet of their religion means violating another. I’m uncomfortable asking them to make a choice between these two values.

What would have been a better way of handling this issue? In his Washington Post column, E.J. Dionne advocates a proposal that would require religious groups to inform employees if they were not covering birth control and describe “alternative ways for enrollees to access” low cost contraceptives. Under the circumstances, I think this would have been a better solution. but there’s no denying the unfortunate and frustrating truth that it would have made it more difficult for many women to access reproductive health services.

I firmly hope that the Catholic Church changes its stance on birth control in the near future, and I remain cautiously optimistic that they will, given that the vast majority of Catholics use contraceptives. However, until they do, I’m not sure the coercive response of the Obama administration is the best course of action. It’s never easy resolving these cases in which such fundamental principles come into conflict with one another, but there are times when liberalism must be tolerant of practises that are somewhat illiberal in themselves. I believe this is one of those times.

I linked yesterday to a Times Magazineprofile of House Majority Whip Kevin McCarthy. Included in the story are a few neatly illustrative portraits of idealistic newcomers arriving in D.C. and very quickly discovering their priorities as politicians are not the same as those they had as candidates. An example:

Today the whiskerless doctor who campaigned against Obama’s “socialist” agenda and “the destructive consequences of unnecessary government meddling” is a congressman. Barely three months into his tenure, [Tennessee Republican Scott] DesJarlais found himself signing a joint letter to President Obama to request “crucial” federal assistance for flood victims in his district. McCarthy’s whip office helped throw together a manual for DesJarlais and other freshmen representing disaster-stricken districts. The document, which includes contact information for FEMA and other federal agencies, implicitly strikes a note of caution: the government you bashed in 2010 is the government you may need in 2011.

Another:

[Wisconsin Republican Sean Duffy] expressed discomfort to McCarthy over the votes in January to repeal aspects of Obama’s health care bill. The Republicans, he said, should have solutions of their own. McCarthy assured him that “there’ll be replacement legislation after the repeal, trust me.” Duffy stayed with his party on those votes. But he couldn’t vote to defund NPR, given his rural district’s reliance on public radio for weather updates and news.

A third:

Still, the old bulls can deliver some comeuppance to the insurgents ... Another committee member says: “They’re starting to wake up. I’ve had a bunch come to me and say, ‘I have a horrible flooding problem, I have a bad bridge.’ And I say, ‘Well, then, you shouldn’t have voted for the earmark ban!’ ”

There's a temptation to smirk at the hypocrisy of these freshman Tea Partiers, whose supposed anti-government views ameliorate at the first sign of disadvantage for their district. But that's the wrong attitude to take. It's perfectly reasonable for the representatives of Wisconsinites and Tennesseeans to want to ensure government bodies like FEMA and NPR continue providing necessary services to their constituents. What's not reasonable, in that light, is this:

In previous months, these “listening sessions,” as McCarthy calls them, focused on the Republican budget legislation written by Paul Ryan and taken to the House floor in April. The initiative would shrink the percentage of federal government spending (relative to gross domestic product) to pre-Great Depression levels, convert Medicare to a sort of voucher system, shift more of the cost of Medicaid to states and preserve the Bush tax cuts for wealthy Americans ... The freshmen overwhelmingly supported what Ryan was up to — to the extent that McCarthy and the House Budget Committee chairman would murmur to each other: “Wow. We can go further on entitlements. If we don’t, these guys probably won’t even support the bill.”

Tea Party congresspeople who believe their constituents benefit if the government provides relief after natural disasters, or provides a news and weather service in a part of the country where private enterprise has not filled the gap, should ask themselves why those same constituents would not benefit from the government ensuring they have access to affordable health care. After all, if it's appropriate for government to help the small number of people whose lives are disrupted by flood, surely it should also help the significantly greater quantity of people whose lives are disrupted by illness or injury?

This summery looking photograph is a shot of the one Independence Day I actually spent in America. That's Seattle's Gas Works Park on the Fourth of July in 2010. I think if the Founders had lived in the Pacific Northwest, they would have stayed inside and not bothered to revolt against the English. I ended up going home and watching the fireworks from the roof of my building while wearing a thick sweatshirt.

The next day, of course, was clear, warm and sunny. Now, how about some links to celebrate America's birth?

Big news of the week was finding by the Sixth Circuit Court of Appeals that the Affordable Care Act is constitutional. For the first time, a judge appointed by a Republican agreed that the law was valid. Judge Jeffrey S. Sutton, a George W. Bush appointee and former clerk for Antonin Scalia, concurred with the ruling. The decision is here [PDF]. A portion:

That brings me to the lingering intuition—shared by most Americans, I suspect—that Congress should not be able to compel citizens to buy products they do not want. If Congress can require Americans to buy medical insurance today, what of tomorrow? ... Few doubt that the States may require individuals to buy medical insurance, and indeed at least two of them have ... Yet no court has invalidated these kinds of mandates under the Due Process Clause or any other liberty-based guarantee of the Constitution. That means one of two things: either compelled purchases of medical insurance are different from compelled purchases of other goods and services, or the States, even under plaintiffs’ theory of the case, may compel purchases of insurance, vegetables, cars and so on. Sometimes an intuition is just an intuition.

It is now the law of the United States that video games are art. It is now the law of the United States that video games are a creative, intellectual, emotional form of expression and engagement, as fundamentally human as any other.

Then there’s the uglier side of Perry’s rule. The state is looking at a staggering $27 billion deficit for 2012-2013. Perry managed to paper over Texas’s last budget shortfall by taking $6.4 billion in Obama stimulus money, more than all but two governors. (At the same time, he was suggesting Texas should secede from the union.) Now, without Democrats in Congress to bail him out, Perry and other Republicans in Austin are proposing big cuts to Medicaid and education—this in a state where 26 percent of people are uninsured, the highest percentage in the United States.

It’s doubtful, for instance, that Republican caucus-goers or primary voters will be upset by the sort of insult-laden outrage expressed recently by Rolling Stone’s Matt Taibbi in his review of Bachmann’s ideological history. But you have to assume that more than a few Republican elites are worried about her recent ascendency, and the possibility that she could quickly eliminate the inoffensive conservative alternative to Mitt Romney, Tim Pawlenty, in Iowa, creating a divisive slugfest down the road.

After the jump: DC dance music, the power of Stephen Colbert 's parody, and an unlikely defender of illegal immigrants

Bridges is an unlikely soldier on the front lines of the nation's immigration debate. The 58-year-old native Southerner describes himself as a conservative Republican. For years, he knew little about immigrants but didn't lack strong opinions about them: "They were just low-class people," he recalls. "They weren't even able to speak English."

The Times gets it wrong in saying that his super-PAC originated in a skit but “became real.” The point of parody is that there is both never a joke and always a joke, that the thing is real as soon as it becomes expressed. What the FEC has done is not make it more or less real, but legitimate.

Conservatives used to be the ones with heads firmly based in reality. Their reforms were powerful because they used the market, streamlined government and empowered individuals. Their effects were large-scale and important: think of the reform of the tax code in the 1980s, for example, which was spearheaded by conservatives. Today conservatives shy away from the sensible ideas of the Bowles-Simpson commission on deficit reduction because those ideas are too deeply rooted in, well, reality. Does anyone think we are really going to get federal spending to the level it was at under Calvin Coolidge, as Paul Ryan's plan assumes? Does anyone think we will deport 11 million people?

Moombahton, a blogged-about type of slowed-up electronic dance music, began in a suburban Washington, D.C., basement in the fall of 2009. Dave Nada’s teenaged cousin asked the DJ to spin at a midday “skipping party,” wherein high-schoolers leave class early and go over to someone’s house and party. Nada, nearly twice the age of the kids, wasn’t exactly sure what to play to get them moving. He did, however, notice that they’d been blasting lots of reggaeton. So he fit the more relaxed pace of reggaeton by reducing the speed of Dutch house music ... “The internet was crucial for its growth and it still is,” Nada says. “‘Born in D.C., bred worldwide’ is the tagline.”

Over the last quarter-century the love that dared not speak its name turned into a veritable motor mouth, to a point where the average American, according to an astonishing Gallup Poll last month, thinks that about 25 percent of the population is homosexual. Hardly. But that perception underscores how visible gay people have become. And familiarity changes everything.

Ryan Adams's "New York, New York," with its video inadvertently showcasing the World Trade Center in the days before it was destroyed, has become closely associated with 9/11. The lyrics, however, say the singer "shuffled through the city on the Fourth of July/I had a firecracker waiting to blow." Let's enjoy the tune in that light. Happy Independence Day, everyone.

In an obscure corner of the internet, you can find one of my more shameful efforts at political analysis. In October 2009, on a little-read blog, I made a rather silly prediction. When the New York Timesreported that Republicans were optmistic of gaining 40 seats and taking control of the House in the 2010 midterms, I declared such "wishful thinking" as "utter fantasy."

Republicans ended up gaining 63 seats, and a majority in control of the House. Oops. Mea culpa.

In spite of this success, however, this does not feel like a particularly Republican moment in history. The party's presidential field is weak, and shows few signs of getting stronger. Recent polls show that electors both expect Barack Obama to be re-elected and believe he deserves a second term. The House GOP has won some policy victories, reducing spending, and making it harder for women in the District of Columbia to get abortions, but the big political wins over the past few months have belonged to the president. The Tea Party has lost much of the energy that thrust its acolytes into power, and those representatives are finding it much harder to make significant cuts to spending than they had previously supposed. I have learned my lesson, and I am not about to predict the results for the 2012 presidential contest, but at the moment, the task of making Barack Obama a single-termer is more daunting than an ascendant Republican Party would hope.

One of the Republicans hoping to achieve that goal is Newt Gingrich. He's making a not very credible bid to become the Republican presidential candidate, and to coincide with his entry into the race, Mother Jones has uploaded its seminal profile of the former House Speaker. Originally published in 1984, it is a wide-ranging of the hypocrisies, immoralities, and talents of the then young Congressman from Georgia. It's definitely worth a read. What particularly caught my attention was one of the more complimentary statements about Gingrich:

Gingrich has coined a slogan to communicate his vision: a "conservative opportunity society"—the opposite, at least in language, of the liberal welfare state. Its three pillars are free enterprise, high technology, and traditional values. But unlike the Republicans of the past 50 years, Gingrich is not content simply to object to every liberal spending program; he seeks to develop a new, positive agenda for the nation. He is not antigovernment, but antiliberal. "I believe in a lean bureaucracy, not in no bureaucracy," he said. "You can have an active, aggressive, conservative state which does not in fact have a large centralized bureaucracy...This goes back to Teddy Roosevelt. We have not seen an activist conservative presidency since TR."

And this explains the GOP's problem. The party found success in strenuous opposition to a Democratic Party pushing contentious reforms to health care and governing during a period of high unemployment, but they never really came up with much of an alternative agenda. The best evidence of this lies in the party's distinct failure to even try to enact the "replace" portion of their "repeal-and-replace" promise on health care. Elsewhere, Paul Ryan's highly unpopular Medicare reforms are as unoriginal as they are unworkable. Whatever one might have thought of Republican ideas in the 1980s and '90s, or the way they implemented, there was no doubt that they had them. To improve his party's long term fortunes, 2011 Newt Gingrich might want to look back to 1984 Newt Gingrich for inspiration.

The Americans look at Canada, Europe and Australia, where the government is the payer. Maybe we ought to adopt their model. And the Europeans and the Australians are saying, "You know, this isn't working very well, maybe we ought to adopt the U.S. model."

This has me completely mystified. Certainly, there are many ways Americans can learn from the Australian health care model, but I know of no suggestions in Australia to shift to anything like an American health care system. The very idea is preposterous. I know Americans believe they have the best health care system in the world, but there is no envy for it here. We are well aware that it's poorly run and highly expensive. Australians don't think our health care system is perfect, but there is bipartisan support for our single payer model, and any hint at changing to anything even vaguely like the US model would terrify voters. I really wonder on what basis Christenson is making this assertion.

And... so? Parties commonly use the names of bills to frame the public's perceptions of them, and though "Repealing the Job-Killing Health Care Law Act" is clumsier ("law act"?) and more shameless than most, it's naming is not materially different from the USA PATRIOT Act or the DREAM Act. I'm pretty sure we can all tell that when the GOP names a bill "Job-Killing," it has nothing to do with person-killing.

This is exactly the kind of banality America should avoid if it really is to "change the national conversation." Because if there's anything wrong with the title of the repeal bill, it is its disingenuousness, not its imagery. The Affordable Care Act is not killing any jobs, and I feel pretty secure in saying the Republican leadership knows this. From the link above:

In a statement sent my way, [spokesperson for House Majority Leader Eric Cantor] Brad Dayspring confirms, "As the White House noted, it is important for Congress to get back to work, and to that end we will resume thoughtful consideration of the health care bill next week. Americans have legitimate concerns about the cost of the new health care law and its effect on the ability to grow jobs in our country. It is our expectation that the debate will continue to focus on those substantive policy differences surrounding the new law."

Cantor's office knows perfectly well that the Congressional Budget Office found the Affordable Care Act will save money, and that the Republican repeal would increase the deficit by removing those savings. Political rhetoric requires honesty as well as civility, and these sorts of mistruths do far more to degrade politics in America than references to job-killing. The name of this bill is as foolish as it was last week, and Republicans weren't interested in changing it then, so why should they change it now? Really though, since this is a piece of grandstanding that will not be passed this Congress and will be forgotten soon after the Senate rejects it, the naming issue is as irrelevant as the rest of the legislation. Let's get on with it, America.

Lesley's round up of yesterday's Virginia court ruling finding part of the Affordable Care Act unconstitutional was excellent, but there's one small part I take quarrel with. That's the blithe prediction from Ian Millhiser that district court Judge Henry Hudson's opinion "has no chance of convincing the Supreme Court to strike down the law." That's a smart, well-reasoned analysis that could just be one hundred percent wrong.

To be clear, Judge Hudson's decision was rather unusual. There's nothing about the health care bill that suggests it's out of step with the past eighty years of precedent in regarding the commerce clause. Courts have interpreted broadly the provision allowing Congress authority over legislation relating to commerce among the several states. A tax levied on Americans who do not purchase health care is not a radical proposition. But this has become a politicized case, with opponents to the bill digging up an antiquated understanding of the constitution to support their opinion.

The New York Times suggests Ken Cuccinelli, the Virginia Attorney General who filed the suit, was motivated by political as well as legal concerns, and only one of the state attorneys general who has filed suit against the law elsewhere is not a Republican. Judge Hudson was appointed by President George W. Bush and has a stake worth between $15 000 and $50 000 in a GOP political consulting firm that worked against the health care reform. Two other district court decisions, both finding in favor of the law's constitutionality, were decided by judges appointed by Democrats. And don't forget, earlier this year, prominent law experts were almost universally in agreement that the suit was frivolous.

It still is frivolous, only it now has some judges willing to heed that frivolity. Until recently I would not have thought such judges might be sitting on the Supreme Court. Not so much because I think the sitting justices are strikingly sober-minded individuals, but because in recent times, absent the rather glaring exception that was Bush v Gore, the Supreme Court had been leery of doing anything radical.

The last few years of the Rehnquist court and the first few of the Roberts one were characterized by reservation and deferral to Congress and established precedent. The court was not comfortable with bold decisions. Striking down the health care bill on an unconventional reading of the constitution would be quite outside its wheelhouse.

But of late, the Roberts court has had a lot more time for overturning well established precedent, and has been more willing to listen to novel legal ideas. This was most prominently seen in recent decisions like McDonald v Chicago, which overruled a well established interpretation of the Second Amendment, and Citizens United v Federal Election Commission, which did the same for campaign finance law. Though it is more likely to than not, considering its recent form, I can't be certain this court will uphold the constitutionality of the Affordable Care Act. Ultimately, it all comes down to what Anthony Kennedy thinks.

As Lesley mentioned, the first steps of the Affordable Care Act, a k a the Democrats' health care reform bill, went in to action yesterday. After a bit more than 24 hours, I can safely report that there are still plenty of folks without insurance, though on the plus side, I haven't seen any tanks rolling down the newly socialist streets of downtown Seattle. That's a cautious thumbs up, then?

We talked a fair bit about health care reform back when the bill was being debated and passed, but if you felt we didn't get enough into the nuts and bolts of the thing, the non-partisan Kaiser Family Foundation has put together a video explaining the whole thing. It's no Schoolhouse Rock, but we'll take what we can get.

I describe the Washington Postarticle in question as having "may" misrepresented some of Newt Gingrich's comments regarding civil rights because the Post's correction is based only on emailed "clarifications" from Gingrich himself. The paper makes no indication that it concedes the reporter in question, Dan Balz, misrepresented Gingrich. Nor does Balz, in his post on the matter on the paper's 44 blog. Neither Gingrich nor Balz, to my knowledge, have offered the relevant quote in full, so it is impossible to know whom to believe; one, either, or both could be dishonest here. However, I cannot see how this squabble could justify James' sweeping condemnation of Krugman, an opinion writer who used a quote from a report that has been disputed after the fact. I do believe, though, that reading the top line results of a poll and reporting them with a link to an ideological blog suggests insufficient inquiry at best, particularly when further exploration reveals a data set contradictory to the narrative at hand.

Republicans will gain a lot of seats in November because American voters currently loathe incumbents, and Democrats are more likely to be incumbents at the moment. This year, that loathing of incumbents looks like it will overcome the public's disenchantment with Republicans, though Republicans can undo that by reminding the public why it does not like the them. I will note that polling guru Nate Silver seems far less impressed by the post-pass bounce than I do, though he thinks it exists. He calls the data "decent, but not great" for Democrats, and speaks approvingly of a Quinnipiac poll. The Quinnipiac poll finds that voters disapprove of the health care reform 49-40 per cent. It does not indicate why they disapprove of it. It also finds that voters disapprove of attempts to challenge the constitutionality of the reform, but are more likely to vote for politicians who opposed the reform. Significantly, however, it finds that gigantic chunks of voters say a representative's vote on health care will not make them any more or less likely to vote for them in November. In fact, most voters will not be less likely to vote for a representative because of their health care vote. Americans right now, above all else, care about the economy, and the economy is still looking pretty awful.

The Rasmussen poll James links to does show that 55 per cent of likely voters favor repealing the bill. It may well be right, even though Rasmussen has a noted tendency to elevate Republican numbers. In America, because voting is optional, likely voters and "Americans" are very different things. As Silver says:

Rasmussen, for instance, is one of the few pollsters to already be employing a likely voter model at this point. It's not uncommon for likely voter polls to have comparatively better results for Republicans, since Democrats rely on votes from groups like young voters and minorities who turn out less reliably in midterm elections. (And, indeed, Republicans appear to have an especially significant enthusiasm advantage in this cycle.)

Rasmussen may indeed be a better predictor of events in November. Congress, however, governs for all Americans, not just likely voters, and if evaluating policy approval, I see no problem with referring to a poll that includes people who are considered less likely to vote next November.

I take polls seriously because, as my previous post demonstrated, they can drive narratives, and if interpreted incorrectly, drive them in a direction contrary to the public's actual point of view. If the only poll that mattered were indeed the one on election day, James should cast his mind back to the most recent national poll, and recall that Democrats won the Presidency, as well as increased margins in the House and Senate. And if he finds discussion of polls uninteresting, he should endeavour to quotepollsless often in his posts.

And so it ended with a whimper, not the bang Republicans hoped their trivial and obstructionist amendments would bring about. Republican Senators, apparently eager to retain the special treatment given to states like Nebraska under the health care legislation signed into law by President Obama on Tuesday, spent the Senate's time offering a few trivial objections to the legislation's reconciliation status, under the apparent impression that such activity would cause great consternation in the House. The House shrugged and passed it, with a 220-207 vote.

Since it became law, Republicans have misjudged the public's appreciation for their attempts to block health care reform, which is no real surprise, because they did exactly the same thing before the Democrat's legislation passed. My colleague James Morrow reported gleefully that a CNN poll conducted last week found 59 per cent of Americans were opposed to the bill. He either didn't know, or didn't care to let you know, that the actual poll [PDF] found that 13 per cent of Americans opposed the bill because it is not liberal enough. That is, a 52 per cent majority of the American population was either in favour of the legislation, or wanted it to go even farther than it did. And despite James' willingness to reproach New York Times columnist Paul Krugman for failing to fact-check a Washington Post article that may have misrepresented some comments from Newt Gingrich, when I emailed James to let him know he hadn't properly communicated the findings of the poll, he disregarded my advice entirely.

But Republicans don't need to look to even the second reported finding on a poll to discover people don't mind Obama's new health care reforms. Gallup reported a new poll earlier this week finding that 49 per cent of Americans think it is a good thing that Congress passed the bill. Only 40 per cent think it is a bad thing. 50 per cent were enthusiastic or pleased, while 42 per cent were angry or disappointed. My guess is that a big chunk of Democrats that had once been upset that the bill was not as liberal as they would like quickly realised they actually were impressed with what Barack Obama had accomplished.

When the House passed the Senate's original legislation this past Sunday, Republican Senator John McCain said, "there will be no cooperation for the rest of the year ... they have poisoned the well." If Republicans believe—and they seem to—that doubling-down on their obstructionist tactics will pay off electorally for them, they're sadly mistaken. They've confused the anger a depression-battered American public has for its government with the enthusiasm their small sliver of a base has for their own right wing ideology.

In 2006 and 2008, Americans threw their support behind the Democratic party because it had credible approaches to confront the problems with the country's health care, foreign policy, and economy. And even though the Democrats aren't as popular as they once were, the Republicans have offered no ideas to convince an American populace the GOP is better placed to solve their problems. The CNN poll I referred to above shows as much; people trust Congressional Democrats to solve major health care over Congressional Republicans on a 45-39 ratio, and President Obama over Congressional Republicans on a 51-39 ratio.

Make no mistake: right now, the American people's dissatisfaction with its government means Republicans will likely gain a lot of seats in the midterms this November. But the best way the party can prevent that from happening would be to confuse that hostility to incumbents with approval of anything Republicans are doing. Because right now, the GOP is doing its darndest to score an own-goal in what should be a mid-term cakewalk. Or do they think Americans will vote for angry, obstructionist candidates who propose to once again allow health insurance companies to reject them based on pre-existing conditions?

The package of changes called HR 4872 has just passed the House, with a final vote of 220-211. This is the Reconciliation bill that amends the Senate's version, which was passed earlier this evening (here's the breakdown of votes). Assuming President Obama signs the Senate bill, it will become law. The Reconciliation still needs the President's approval and the Senate's endorsement before its changes will also become law, however, Republicans will not be permitted to filibuster it. That means it will require a mere 50 votes to pass, assuming President of the Senate Joe Biden would cast his vote in favour.

It seems like a good moment for a tune:

"This health care issue is D-Day for freedom in America ... If we’re able to stop Obama on this it will be his Waterloo. It will break him" - South Carolina Senator Jim DeMint.

(As Matt Yglesias admits, this is my joke. I'm a bit more cautious than he is, however, hence my posting it later.)

Debate has been slowed, but not halted, by a series of Republican requests for votes on technicalities involving the rules, all of which have been reliably defeated. Democrats received a major boost when Michigan Representative Bart Stupak revealed, in a press conference at 4pm D.C. time, that he had come to a deal with the President on abortion provisions; basically, the deal was that Obama would make an executive order requiring that the law follow the law. Stupak then told the press the Democrats easily have the 216 votes required to pass the legislation.

Meanwhile, outside, Tea Party protesters railed against the bill, at times encouraged by some Republican members, though Minority Leader John Boehner described some of the protesters as reprehensible. (Some were; epithets like "nigger" and "faggot" have been shouted by tea partiers at black and gay Congresspeople.) The fray even intruded in to the House, where one "Kill the Bill" protester disrupted proceedings from the Gallery, cheered on by Republican members.

I'm not going to be offering celebrations or analysis until the full time siren blares and the votes are on the score board, but with those votes predicted to mirror the rules tally, it seems safe to say that the Democrats are on the verge of a major victory. (Futures market Intrade gives it a 97.4 per cent chance.) If so, congratulations to all involved, particularly the people of the United States of America who will benefit so greatly.

One of the things I helped out with in the Majority Whip's office while I worked there earlier this year was the production of what is known as the Whip Line. This is one of the simpler parts of the whipping process, and involves letting the other Members of Congress how the Party would like to vote. (The Party does not instruct Members what to do for every single vote.)

The Whip Line for today, unsurprisingly, recommends passage of the Senate's Health Care reform bill, and of the House's package of changes. Here's what it looks like:

Two hours of general debate on the Senate Amendments to H.R. 3950 and on H.R. 4872.

Vote on the motion to concur in the Senate Amendments to H.R. 3590. Members are strongly urged to VOTE YES.

Debate and vote on Republican motion to recommit H.R. 4872. Members are strongly urged to VOTE NO.

Vote on final passage of H.R. 4872. Members are strongly urged to VOTE YES.

It's an understatement t say that this is something the Democrats want passed. One small sign of that: Whip Lines usually use the language "Members are urged to vote yes." That single word "strongly" shows this vote is something a bit special.

The House Majority Leader Steny Hoyer has announced the floor schedule for tomorrow. The House will be naming a post office in Ohio, supporting the goals and ideals of National Women's History Month and... hey, look at this:

The health care votes are the first scheduled for the day. Those in and outside of the United States can tune into C-Span's Web site to watch the proceedings. Australians, 1 p.m. Washington D.C. time translates to 4 a.m. Sydney time. Get up early. I'll be live-tweeting at @jbradleyUSSC, as will Erin at @eirinn22.

Excuse me if I can't quite get worked up over the complaints of James Morrow (whose neighbours all enjoy a single-payer health care system) concerning the deem-and-pass procedure the Democrats appear to be deploying to effect their health care reform. I mean, here in America we're celebrating St. Patrick's Day, and I can figure few better ways of doing that than honoring one of the greatest fictional Irish-Americans of recent years, "The Wire"'s Jimmy McNulty. Here's his (spoiler) supposed wake, accompanied by the Pogues' "The Body of an American." Politics right now seems like it should only concern the day Americans from both sides of the ideological spectrum unite in their desire to be identified with a European nation, one with universal health care and strict prohibitions on abortion. Dear Bart Stupak... have you ever thought about emigrating?

But, if we must, let's examine a few of Morrow's arguments. Fortunately for him, his objections to deem-and-pass, or as it's more properly known, the "self-executing rule," have been examined [PDF] by the Library of Congress' non-partisan Congressional Research Service. Here's what they said in December of 2006. That is, when Republicans controlled both houses of Congress :

One of the newer types is called a “self executing” rule; it embodies a “two-for-one” procedure. This means that when the House adopts a rule it also simultaneously agrees to dispose of a separate matter, which is specified in the rule itself. For instance, self-executing rules may stipulate that a discrete policy proposal is deemed to have passed the House and been incorporated in the bill to be taken up. The effect: neither in the House nor in the Committee of the Whole will lawmakers have an opportunity to amend or to vote separately on the “self-executed” provision. It was automatically agreed to when the House passed the rule. Rules of this sort contain customary, or “boilerplate,” language, such as: “The amendment printed in [section 2 of this resolution or in part 1 of the report of the Committee on Rules accompanying this resolution] shall be considered as adopted in the House and in the Committee of the Whole.”

So, basically, the House, by passing similar but distinct legislation (which will also have to be adopted by the Senate) is agreeing not to get into the nitty-gritty of making amendments. These self-executing rules have been around for decades, and have been used by both Democratic and Republican Congresses to enact legislation. In 2007, they were decided to be permitted under the Constitution.

I must admit, I'm not a big fan of them. My preference would be for Democrats, as well as every single Republican who think it's important to insure 30 million extra Americans and, in doing so, reduce the deficit, to merely vote for the Senate bill, then enact the House Amendments improving upon some of the worst excesses of that Senate bill.

But my preference would also be for Senate Republicans to abandon their abuse of the bizarre parliamentary procedure known as the filibuster. Let's be clear: this widespread use of the filibuster is novel to these past few decades, and can only rightly be seen as an exercise in Republican brinksmanship. America's founders, together with its populace through most of its history, did not intend for the Senate to operate with a super-majority requirement. If Republicans genuinely do not want to see the House use the self-executing rule procedure, they should agree to allow a majority-vote of the health care legislation in the Senate.

But just as filibustering any-and-everything that comes before a member is legal, but not moral; so too is playing fast and loose with House rules. If an obstructionist conservative minority will play cute with procedure, they can hardly complain when their opposition does the same. For now, I'll leave you with a list the CRS maintains of deem-and-pass rules that have been used to enact "significant substantive and sometimes controversial propositions":

On August 2, 1989, the House adopted a rule (H.Res. 221) that automatically incorporated into the text of the bill made in order for consideration a provision that prohibited smoking on domestic airline flights of two hours or less duration.

On March 19, 1996, the House adopted a rule (H.Res. 384) that incorporated a voluntary employee verification program — addressing the employment of illegal immigrants — into a committee substitute made in order as original text.

H.Res. 239, agreed to on September 24, 1997, automatically incorporated into the base bill a provision to block the use of statistical sampling for the 2000 census until federal courts had an opportunity to rule on its constitutionality.

A closed rule (H.Res. 303) on an IRS reform bill provided for automatic adoption of four amendments to the committee substitute made in order as original text. The rule was adopted on November 5, 1997, with bipartisan support.

On May 7, 1998, an intelligence authorization bill was made in order by H.Res. 420. This self-executing rule dropped a section from the intelligence measure that would have permitted the CIA to offer their employees an early-out retirement program.

On February 20, 2005, the House adopted H.Res. 75, which provided that a manager’s amendment dealing with immigration issues shall be considered as adopted in the House and in the Committee of the Whole and the bill (H.R. 418), as amended, shall be considered as the original bill for purposes of amendment.

One of my rituals as an intern in the Whip's office—apart from those mundane tasks like delivering the mail, keeping the photocopier filled with paper and ensuring every staffer has a copy of that day's Politico—was checking the publications put out by the office of the Majority Leader Steny Hoyer each day the House was in session. That way I would know which legislation was to be coming up, and which votes we would likely be whipping on.

Hoyer creates the Daily Leader, which promises for the 15th of March a thrilling day of the House naming post offices, but more worthy of our attention is the Weekly Leader, which lists the House's expected activities for the next five days. This edition, at the end of a run-down of proposed recognitions and expressions of support, contains seven rather exciting, if disappointingly vague words:

Further Action on Health Insurance Reform Legislation

These words are exciting because they haven't appeared in previous editions of the Leader; the Leader discusses business to be conducted on the actual House floor. They're disappointing because "Further Action" isn't the most concrete thing in the world. But it is an indication the House leadership is increasingly confident they can hold a vote on this legislation. And considering that, as Ezra Klein explains, the House Budget Committee has released The Bill That Will Become The Reconciliation Bill, health care reform might just be closer than some of us think.

Well, the USSC's Lesley Russell called it, and now we have confirmation: Barack Obama will be delaying his trip to Australia. Russell's prophecy, from this past Wednesday:

For Australians anxious to see Obama and his family Down Under including surely the Prime Minister and his government the chances of that happening look increasingly iffy. It would be quite difficult for the President to cancel his trip to Indonesia, the political ramifications of that are significant.

But telling an understanding ally like Australia that issues with health-care reforms back in Washington require that a planned visit is rescheduled is an easier matter. Such news should be received with considerable understanding by a Prime Minister just beginning his slog to sell health care reforms prior to an election campaign.

Fortunately for Australia, the visit was not rescheduled, but merely delayed. The New York Times' Caucus blog is reporting that the President will leave three days later than planned; on the 21st rather than the 18th of March, and will leave the wife and kids back in D.C.:

The president’s international trip had grown into a source of frustration among many House Democrats, who complained privately to the White House that they were being forced to take a quick vote on health care so Mr. Obama and his family could leave on the overseas trip next week.

In fact, the president is no longer taking the first lady, Michelle Obama, and their two daughters on the trip, an administration official said. The president agreed to delay his departure from March 18 to March 21, an administration official said, shortening the trip for official business only in an effort to show flexibility in the final push on health care legislation and to give Mr. Obama more time to win over skeptical House members. The three-day delay effectively sets a new timetable for the House vote on the measure.

That new timetable could see the House pass the Senate's version of health care reform as early as next week, according to the Times. The vote would be held on Thursday or Friday if the Congressional Budget Office issues its report on the legislation, and if the legislative text of the package of changes the Senate is to adopt under the reconciliation process can be written in time.

While I must extend my utmost sympathy to Michelle, Malia, and Sasha Obama for having to miss out on this trip, and I commiserate with my fellow Australians, who I´m sure are eager to have the President over for tea and biscuits, I am glad Obama is to stay in the States. While Russell is right to say his visit to Indonesia is too important to America's foreign policy interests to cancel, Obama does not need to be visiting Australia without delay. I have little doubt that seeing health care reform through these final votes, providing 30 million Americans with insurance, and helping to control costs of a dangerously metastasising sector of the U.S. economy is a better use of Obama's time over those three days than anything he may do in Australia. And that includes crumpets with Kev.

I'm sure many Australians will be disappointed by the delay. But if it will help bring America even this small amount closer to the kind of affordable and accessable health care we enjoy Down Under, then we should gladly accept Obama's apologies.

I'll admit, I was fooled too. She'll correct me if I'm putting words into her mouth, but one of the things Erin Riley and I were most excited about seeing during our time in D.C. was Congress as it passed its historic health care legislation. And we're now a week into March, Erin is back in Sydney, and the eagle-eyed among you will have noticed my location listed as Seattle, WA. And health care? Well, on strict technicalities, the reform is stalled exactly where it was on Christmas Day: one House bill, one Senate bill, and nothing on the President's desk.

But forgive my irrational exuberance. A coterie of commentators have exhibited far higher expectations than I ever did, if their dire reports of the state of the Obama administration are any indication.

You don't even need to disdain Mark Knopfler as much as I do to tire of all this talk about dire straits and the White House, particularly when under examination, things don't look too bad for the Obama administration. True, this is not a great time for Democrats: Americans have too little patience with incumbents at the moment, probably because too many Americans are out of work. The economy is still a little too sluggish in its recovery, the deficit is a little too large for anyone's liking, and Charles Rangel's dealings appear to be a little too shady. The party can expect a tough run in the mid term elections.

But if you look a little farther afield than the Times' condemnation of Axelrod, you'll see within its pages a perfectly cogent summation of Obama's political fortunes:

Polls suggest that the public is already on the president’s side. In a New York Times/CBS News survey early last month, respondents were twice as likely to say that President Obama was trying to work with Republicans as they were to say that Republicans were trying to work with President Obama (62 percent versus 29 percent). And by overwhelming margins, they said they wanted both sides to compromise some positions “in order to get things done.”

[...]

In the New York Times/CBS poll last month, 51 percent said they view the Democrats unfavorably, the highest since November 1994, when the Republicans swept into office. But 57 percent said they view the Republicans the same way, near the all-time high of 60 percent.

The paper quotes a Democratic pollster, Stanley Greenberg:

Greenberg ... noted that the energy behind Democrats in 2006 had been building for a year, beginning with anger over President George W. Bush’s handling of Hurricane Katrina and the Iraq war. “The other side got demoralized as they watched our energy,” Mr. Greenberg said. This time, “our side is demoralized by the lack of progress. It’s almost independent of the energy on the other side.”

The Democrats have to do two things, he said. They have to show that they can govern successfully — passing some version of health care reform would be his preference — and then they have to frame the election as a choice for Democrats

Greenberg may be partisan, but his reading is accurate. This is not yet a Presidency on the ropes. For a start, as Matt Yglesias points out, Obama can lay claim to quite a few accomplishments from his first year in office. The President's approval rating, hovering around 51 per cent, is not nearly as high as it was during the heady months after he first took office, but it remains respectably positive. And most importantly, though commentators seem all too eager to elide this detail, health care, Obama's signature reform, is not dead yet. Rather than proving themselves unable to govern, Democrats are nearing the end of a long process of reform that nobody should have expected would be easy.

As my colleague Erin pointed out in an essay written for the USSC last year [PDF], the Obama administration's approach "was not married to any particular version of health reform policy. Rather, it crafted an approach to the manner in which the policy would be shaped and political forces managed." In so doing, Erin argues, Obama has advanced this current attempt at reform closer to realisation than ever before.

Now that the Democrats have gotten over their Scott Brown-inspired shakes and realised that 41 Senate seats does not make a majority, this bill has every chance of making it as far as the President's desk. And while I would have preferred to see Obama campaigning six months ago for this legislation as hard as he is now, and while plenty of people around Washington pinpoint the length of time Max Baucus was permitted to seek the support of Senate Republicans (apparently Obama's fault), Obama has so far been reasonably successful in promoting a difficult and historic piece of legislative reform. Examining his administration's supposed failure is like complaining that, a hundred metres short of the finish line, a marathon runner has taken too long to complete the race.

...is reading things like this in the Times, and wondering if I know the "senior House leadership aide" in question:

Publicly, House Democratic leaders are trying to sound upbeat. The House Democratic whip, Representative James E. Clyburn, Democrat of South Carolina, said last week that he felt “pretty good” about the chances of passing Mr. Obama’s bill. But the leadership has not yet started counting votes, and a senior House leadership aide, speaking on condition of anonymity, conceded that rounding them up would not be easy.

“It’s going to be a heavy lift,” this aide said, “but so have many other votes. In the last health care vote we really didn’t have the majority until the afternoon, and this will probably be that way, too. That’s how these votes come together in the end.”

As the Senate voted for cloture on the health care reform debate over the weekend, it's probably a good time to consider a really important column from Bruce Bartlett on the hypocrisy of some members of the Republican party.

It's an excellent piece, despite a rather sexist illustration that raised my feminist ire, which looks at the current health reform proposals in the context of Medicare Part D, particularly mentioning representatives who voted in favour of Medicare Part D, but are now voting against the current health care reform on the ground that it is fiscally irresponsible.

Medicare Part D was a fairly significant health care reform in its own right. It provided prescription drug benefits for Medicare recipients. It was passed in very odd circumstances in 2003- the House vote, which typically only lasts 15 minutes, was kept open for three hours, enabling supporters to convince some members of Congress to change their vote.

One of the most remarkable aspects of the Medicare Part D bill is that it prohibited Medicare from using its considerable purchasing power from negotiating with drug companies to ensure lower prices. Consequently, the cost of medication under Medicare Part D is substantially higher than under the comparable Veteran's Health service, which was able to use its purchasing power to negotiate.

And how was this expensive reform financed? Why, using the deficit, of course.

Unlike the current health care reforms, which are not only deficit-neutral, but actually will reduce the deficit within a ten-year window, the Medicare Part D reforms were financed entirely from the deficit. And there is strong evidence that the true costs of the bill were obfuscated: Medicare's then-chief actuary, Richard Foster, concluded the bill would more like cost $534 billion. He was silenced by his superiors, who warned that releasing the information was illegal. (Read Foster's account of what happened here) And so the bill passed, grossly inflating an already-enormous budget.

Where was the populist outrage then?

Perhaps the most distasteful part of this affair is the way many Republicans who voted for this bill are now voting against health care reform, and framing their opposition in terms of the deficit. Before them is a fiscally-responsible bill that will dramatically increase the number of Americans who will have access to affordable health care, yet they raise concerns about the deficit and the cost of the bill as justification for their opposition to it.

Republican lawmakers can by all means, oppose health care. There are many fair and genuine reasons to do so: some have to do with the role of government, some with opposition to raising taxes.

But voting for the fiscally irresponsible Medicare Part D, then against the current health care reforms because of concerns about the deficit is hypocrisy, plain and simple.

On Sunday afternoon, I ignored the lure of the great outdoors and sat in front of my computer, watching C-Span. The House was about to vote on Health Care reform. It was 11pm on a Saturday night, DC time. The four hours allotted to debate hadlapsed, and it was time to finally take the vote.

Watching online, it was amazing to see the galleries and floor packed. Staffers and the public have filled the chamber, all to see this historic piece of legislation pass.

And it is an historic piece of legislation. Barack Obama and the Democratic congress have done what no president since Johnson has been able to do: get a health care bill through the House of Representatives.

So many presidents have tried. Johnson was the last to succeed, but since, it's been failure after failure. Ford, Nixon, Carter, Clinton- all tried, all failed. Certainly, the Bush administration passed Medicare Part D (which deserves countless posts on its own), but comprehensive health care reform hasn't happened in the last 40 years.

It was remarkably fun to follow the action live: watching the debate, and reading the responses people around the United States, and around the world, were having to the occasion. Twitter went crazy, with comments from people on both sides of the aisle. #HCR, the official health care reform hash tag, was one of the most popular topics of the day.

In the cacophony of voices discussing the bill, some stood out. Pundits who knew the legislation inside and out were able to offer expert commentary, explaining developments as the debate progressed. Personally, reading the insights of noted health care reform bloggers like Jon Cohn of The New Republic and Ezra Klein of the Washington Post was invaluable. They made the experience both more understandable, and more enjoyable.

Plus some of the snarky comments were just plain funny.

It was a communal experience. Across the globe, we were able to witness the debate, then the vote, and participate in a conversation about it. We could share our thoughts, excitement, outrage, concerns. When the final vote was cast, some of the Americans I follow on Twitter spoke of toasting with their drinks, late on a Saturday night. I toasted with my early-afternoon coffee.

It was an historic day, not merely because this was the first major health care reform to pass in 40 years, but also because we could experience it in new, digital ways.

It wasn't quite Grand Final day for health care reform today, but the excited atmosphere surrounding the U.S. House of Representatives' vote was something close. Call it a semi-final, perhaps; one that ended with a 220-215 final score in favour of passing H.R. 3962: Affordable Health Care for America Act. 219 Democrats voted for the bill, and one Republican: Joseph Cao, a Louisianan representing a heavily Democratic district, who won election against an opponent who was under indictment on corruption charges at the time.

That makes it sound easy, but anyone who has heard the adage that watching the creation of legislation is like seeing a sausage get made can guess that something as contentious as health care reform was no cakewalk. As with a big game, it all kicked off when House Democrats were given a pep talk from Coach Barack Obama, who told his team, "When I'm in the Rose Garden signing a piece of legislation to give health care to all Americans, we'll look back and say that was our finest moment." I like to imagine his speech was followed up with one from Offensive Coordinator Rahm Emanuel, warning, "Winning isn't everything; it's the only thing." (Or perhaps, "If you lose, you're out of the family").

The vote came at the end of a long and precarious day of negotiation, stalling and deal making, and those of us who don't mind seeing the Congressional sausage factory in action got to enjoy (or endure) crucial votes on whether government should cover the cost of abortions - an amendment by Michigan Democrat Bart Stupak mandated that it should not, and in so doing garnered valuable support from anti-abortion Democrats and an endorsement from the United States Conference of Catholic Bishops. Then there was a "motion to recommit," a crafty parliamentary manoeuvre by Republican whip Eric Cantor that threatened to stall passage; that was defeated 247-187. The House even held a vote to decide whether the bill should be debated at all; it was passed 242-192, allowing the show to get under way. Thank god it did, otherwise we would have missed hearing bold declarations like that of Michigan Republican Pete Hoekstra that he was voting against the bill because "that's the vote that says ‘I love my country'."

The significance of this vote shouldn't be underplayed, but it shouldn't be overplayed either. Health care reform still has to pass the Senate, something far from guaranteed, since the 100 member chamber requires 60 votes simply to end debate and bring the bill to a vote. Senate Majority Leader Harry Reid has warned he might not be able to meet Obama's Christmas deadline for the bill. And even if the Senate can be persuaded to vote yes, their version of the legislation will not be identical to the bill the House just passed, requiring the two houses to enter the precarious process of reconciliation to come up with a single piece of legislation for Obama to place his signature on. The American system of government does well to prevent hasty and unpopular decisions - that's why the Republicans couldn't dismantle Social Security in 2005, even though they controlled both houses and George W. Bush had campaigned with it as a policy for his second term - but it does make big legislative reforms like Obama's health care plan a slog to enact.

But as laborious as the process is, America is now closer than at any point in its history to achieving health care reform. Bill Clinton got nowhere near this point with his attempt in the ‘90s. And it's a demonstration that despite the vocal Republican opposition and the suggestions that last week's gubernatorial votes in Virginia and New Jersey were a decisive rejection of Obama's policies, the political momentum is still very much with the Democrats. Bill Owens, the Democrat who benefited from the splitting of the Conservative vote in the special election in New York's 23rd district, provided a crucial Yes vote for the Health Care bill. And while the New Jersey and Virginia votes remain a real morale booster for Republicans, there's been a steady flow of opinion counter-balancing attempts to frame the votes as a resurgence of the right, pointing out that the votes in those states reflected local and candidate-related issues, not national ones, and that of the five special elections held since Obama won the presidency a year ago, Democrats have won them all. Health care reform is steadily gaining an air of inevitability that will boost its chances of passing, and while things won't be easy for Democrats in the 2010 midterm elections, getting a bill passed will help all of them, from the most leftist liberal to the most centrist Blue Dog. And considering the health care bill was accompanied by a relatively subdued Tea Party protest, it seems the outrage voiced by that niche doesn't have the widespread popularity Obama's opponents attribute to it. After a week dominated by Republican victories and a slew of stories about Obama's lack of accomplishments, this vote will be a serious boost to Democratic fortunes.

***

One aspect of the American system is that party discipline is weaker than it is in Australia, meaning local voters can check on how their individual representative - as opposed to his or her party - voted on a bill. The New York Times has a map showing who voted and how.

And, speaking of sports, if you were watching the World Series last week, you might have see the jaws of some of the players masticating furiously. Perhaps you're not as ignorant as I am, but I was shocked when, a few years back, an American friend informed me they were chewing tobacco, not gum. Slate has a history of this odd practice.

There is a simple electoral arithmetic underlying Kevin Rudd's handling of boat people. The Australian electorate breaks into three basic chunks. On average over the years, some 40 per cent vote Labor. On the other side, about 40 per cent vote for the Coalition. And the other 20 per cent sit in the middle, switching from one side to another from time to time.

Crudely put, the party that can persuade most of that 20 per cent to swing its way wins government.

Labor believes voters on the left are pretty much captive. They have nowhere else to go. They could go to the Greens, who are calling for the 78 asylum seekers on the Oceanic Viking to be brought to Australia immediately.

But even if they were to vote Green, Labor would very likely recover their support through the preference system. So the lost primary vote from the party's left would flow back into Labor's catchment on the all-important measure of the two-party preferred count, the one that decides who wins government in the central struggle of Labor against the Coalition.

But disenchanted voters at the right-wing end of the Labor spectrum will migrate directly to the Liberal or National parties, which are still perceived to have a Howardesque tough-on-boat-people character. They are lost Labor votes that will add directly to the Coalition tally on election night.

So when the interests of the two groups, the base and the swingers, come into conflict, Rudd will almost invariably emphasise the swingers and chose the more centrist or right-leaning option.

In America, because they don't have mandatory voting, the maths is different, and this results in very real differences in the way their government works. We'll ignore for a moment that the numbers in the States don't conform to the 40-20-40 split Hartcher identifies in Australia (if that even is the split here) - a shrinking plurality of Americans identify as Democrats, a larger proportion of Americans identify as independents and more Americans identify as conservatives than moderates or liberals. The basic point is that some chunk of the population is usually going to vote Democrat, another chunk will usually vote Republican, and a third chunk in the centre is willing to go to the dance with whichever suitor shows up looking best on the night.

In this way, America is just like Australia. But unlike here, voters in the United States who would never vote for their disfavoured party have options: they can stay home and not vote at all, or they can vote for a third party. And since these voters - the base - are more likely to be politically engaged with their party, their lack of enthusiasm may multiply and cost the party more than that one voter's vote. Perhaps that voter won't volunteer to man the phones and help turn out other voters. Perhaps she won't feel like donating to the party this year, affecting the funds it has to promote its candidates. That's why, for instance, the former President George W. Bush was so eager to keep the religious right happy (even though I don't believe he did that much to advance their interests): because they devoted their time, votes, and energies to re-electing him. And that was part of the problem John McCain had against Barack Obama last year; conservatives just weren't that enthusiastic about getting him elected.

To be sure, the American maths (or, if you will, the "math") still benefits the centre. Every Democrat voter the Republicans can convince to cast a ballot for them brings a net gain of +2, because switching a vote increases the Republican tally by one while simultaneously diminishing the Democrat tally by one. It works in reverse, as well, of course. But while plucking a voter from the other side is twice as valuable as convincing a member of the base to come to the polls instead of staying at home, turning out a member of the base is still gaining a vote the party would not have otherwise received.

The real influences a voting system like this has can be seen in the health care debate. In August, the public option looked deader than dead; Democrats were singing "Danny Boy" in its honour and sending flowers to its widow. And yet, the liberal base could just not let it go, and because a hostile base will cause all kinds of electoral problem down the track, here we are in October and the discussion is not even about whether the Senate bill will include a public option, but what exact form the public option will take.

Of course, other influences were at play as well. Liberal senators like Jay Rockefeller, who aren't constrained by strict Westminster-style party discipline any more than their centrist party-fellows, started making their unhappiness at the Democrats' concessions known, in a way that would be quite impossible for a left wing Australian Labor Party member to do outside the closed-door confines of the party room. Similarly, an Australian politician with enough ideological conviction and personal appeal can pull the country in the direction of his party's base, even while Hartcher's centre twenty percent retains its reservations - as John Howard did with the GST. But all things being equal, the American political system is set up to allow a far greater range of views to influence policy than the Australian system.

That is not to say the Australian system is without its advantages. Our moderating, mandatory-voting centre ensures energetic, well-funded and unrepresentative interest groups have a tougher time hijacking debates. Our system ensures party members have to spend less time on fund raising, because they don't have to worry about turning out the base. But there is something to be said for a democracy of the American sort, that makes its decisions by paying heed to more than just the small sliver of voters in the centre who are willing to change their minds every now and then.

I like maps like these, because they demonstrate the great diversity to be found within the United States of America, and how important regionalism is in the country. I posted it along with some commentary a couple weeks back on my other blog, but it originally comes from FlowingData.com. (Should you not like pictures, you can see the figures in table form over at Business Week.) The disparity should not be too surprising; the United States has a federal system of government, and while the Founding Fathers may not have intended for Hawaiians to live an average of eight years longer than residents of the District of Columbia, they set up the country on the understanding that the states were not uniform and conditions therein were not interchangeable.

The disparities among the states that cause the differences in life expectancy are not too hard to see; people tend to live longer in states that are wealthier and live more healthful lifestyles. States with modern professional economies tend to do well, as do states that lean Democrat, though that correlation may not necessarily be a cause.

Something that obviously does correlate with and cause longer life expectancy - though even it is not everything - is health care. It should be no surprise that the long-living Hawaiians have one of the best health care systems in the country, and similarly long-lived states like Iowa, Vermont, Minnesota, Maine, and New Hampshire have comparatively cheaper, more readily available, or better quality health care systems. It's not rocket science: if it's easier for you to see a doctor, you'll probably live longer. Similarly, even though other factors like income play a significant role, states with poor health care, for instance Southern states such as Louisiana and Mississippi, have below average life expectancy rates.

The big talk around health care reform in the States this past week or so has been Senate Majority Leader Harry Reid's endorsement of a public option, with an opt-out provision. This basically means that the government would set up a health care system, but if individual states decided they did not want to make use of that option, their citizens could not be a part of it, and the government would not offer insurance in that state. Politico describes it as "a very American idea," saying,"[o]ur founders established the notion of federalism to allow states that felt strongly about public policy to operate under different laws and procedures." As Politico goes on to explain, opting out isn't as straightforward as it sounds. It isn't clear how states would decide to opt out - should the legislature decide? The governor? The people, by referendum? If a state chose to opt out, would the sick migrate to a state that did offer public insurance? And does the government really want to create a precedent of allowing states to pick and choose which federal laws apply to them?

These are all questions that will be answered during the long process of the Senate writing, debating and approving the legislation. But one likely pitfall of the opt out provision may not be realised until it's actually in place and states actually are opting out.

Back when Congress passed a stimulus package aimed at injecting funds back into the American economy, Republican Governors like Louisiana's Bobby Jindal and South Carolina's Mark Sanford made a show of rejecting the Federal hand outs - whether for reasons of ideology, grandstanding, or both. Some, like Mississippi's Governor Haley Barbour were concerned they'd be obliged to accept welfare conditions of which they did not approve, while Jindal and Sanford were, at the time, possible 2012 Presidential nominees who had an incentive to please the Republican base.

The opt-out provision could become a similar political football, and if Governors like Jindal and Barbour are once again the ones kicking it around, citizens of the states who could most benefit from health care reform will suffer. Remember, states like Jindal's Louisiana and Barbour's Mississippi are poor states with little health care coverage that would definitely benefit from a government program.

When the stimulus package passed, a South Carolina Representative, Jim Clyburn, inserted a provision into the bill to allow state legislatures to override any Governor who rejected federal funds. (Disclosure: I will be working as an unpaid intern in Clyburn's office for a period next year.) To ensure health care remains about insuring more people, it might be a smart idea for an opt-out public option to include a similar safeguard.

Elsewhere, if you liked my post about Maine's place in America's future, you might like to take a look at Politico's profile of its senators and its political culture. It gives an excellent overview of the reasons why this odd little state is at the centre of so many of the country's big battles.